HEALTH, EDUCATION, and \ WELFARE ' U.S.DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Office of the Secretary ——C A FR FAIS - - - 3, SE RSS a 5 = aid NEW DIRECTIONS { in Health, Education, and Welfare Background Papers on Current and Emerging Issues 1963 The Tenth Anniversary of the UNITED STATES DEPARTMENT, OF HEALTH, EDUCATION, AND WELFARE, OF Anthony J. Celebrezze, Secretary Wilbur J. Cohen, Assistant Secretary (for Legislation) Office of Program Analysis OFFICE OF ASSISTANT SECRETARY (FOR LEGISLATION) Wilbur J. Cohen, Assistant Secretary OFFICE OF PROGRAM ANALYSIS Luther W. Stringham, Director PROGRAM ANALYSIS OFFICERS PROGRAM COORDINATION OFFICER Joseph W. Kappel Irvin E. Walker Dr. Grace L. Hewell Dr. Earl E. Huyck STAFF ASSISTANTS PRT 5C WEALTH LIB. Eugenia Sullivan Florence Campi ~F / { ! REPRINTS OF SINGLE ARTICLES Single copies of a given article in reprint form may be obtained, while the supply lasts, from the Office of Program Analysis, Office of The Assistant Secretary (for Legislation), U.S. Department of Health, Education, and Welfare, Washington 25, D. C. Users may reproduce these articles in quantity for sending to the subscribers of their own journals, or for student, debate, citizen, em- ployee or other groups for information and discussion. Notification of such reproduction will be appreciated. ‘New Directions in Health, Education, .and Welfare is for sale by the Superintendent of Documents, U.S. Government Printing Office, Washington 25, D.C., at per copy. ii 269 + A= FOREWORD ) 9 ¢ / -— Ves ls We LTH RHE New Directions in Health, Education, and Welfare contains a series of selected papers on important public policy aspects of health, education, and welfare. It commemorates the Tenth Anniversary of the creation of the Department of Health, Education, and Welfare in 1953 and reviews some of the challenging problems of key concern today. New Directions is the outgrowth of the analysis undertaken during the past two years of program developments and needs in the fields of health, educa- tion, and welfare which are the responsibility of the Office of Program Analysis under the supervision of the Assistant Secretary (for Legislation). It incorporates papers that have contributed to the development and better understanding of public programs, both by the executive and legislative branches. Each paper attempts to define the problem; marshals relevant background statistics and other facts; summarizes current efforts, public and private; and anticipates prospective needs or developments. The nation as a whole is spending about $101 billion this year in private and public monies on health, education, and welfare. Approximately one-third of this consists of private funds, and the other two-thirds, of public funds. The partnership between private and public agencies is characteristic of health, educa- tion, and welfare activities in the United States. Continuous review of important policy issues and the search for meaningful new directions in policy are of concern to Federal, State, and local governmental units; private agencies; and individuals. A key feature of the ten-year period since the establishment of the Depart- ment is a change of emphasis from amelioration to prevention and rehabilitation. The newly-born Department of Health, Education, and Welfare took over functions which in large measure looked back to problems created by past emergencies or depressions and other types of crises, functions designed to help people adversely affected by these problems, whereas the Department of 1963, while making a major effort to improve its ‘‘ameliorative’’ programs, is stressing solutions to present and emerging problems. The shift in emphasis from amelioration to prevention has developed, in large measure, by means of the major legislative changes in the fields of health, education, and welfare that have been enacted over the past ten years. This legis- lation has effected needed improvements and new directions in basic statutes gov- erning the programs of the Department, and has also established important new pro- grams of Federal assistance to the States and local communities to help solve pressing health, educational and social problems. As part of the new directions in policy, continued attention must be given to ways and means of emphasizing the preventive aspect in all programs. As a first edition, this volume does not cover the full range of health, education, and welfare subjects that confront the official and challenge the citizen. It will be supplemented regularly by additional papers featured in the Department's monthly Health, Education, and Welfare Indicators. 894 In the development of this publication many agencies and individuals have made major contributions. In several fields they have provided the first such comprehensive overviews prepared for public use. The creativeness and persistence of two persons on my staff--Luther W. Stringham and Earl E. Huyck--have contributed greatly to the shaping and substance of this much-needed document. A 20th century English philosopher, Alfred North Whitehead, said that most of the terrible sufferings that accompanied the Industrial Revolution were not caused by the steam engine or the power loom. Instead they were the consequences of a giant step in technical innovation with no corresponding step at all in social, po- litical, or economic innovation. Today, in the age of automation, the same defi- ciencies are the root of our trouble. The objective is to make full use of our Nation's huge technical capacity and its wealth of potential human resources. The miraculous progress our country has made promises the possibility of improved material abundance, good health, and more leisure time for all. An un- fortunate byproduct of change, however, is man’s difficulty in making the necessary changes in his social, economic, and political institutions in the face of such whirlwind development. Change does not go step by step, pausing to allow us time to adjust to each step. Rather, it is an ever-steepening curve upward and presents not only the task of adjusting to today's world but, at the same time, of preparing for to- morrow's. Our urban centers grow larger and larger. Where there was farmland yesterday, a community has blossomed--tied to a cultural core perhaps 10, 15, or even 20 miles away. And the core--the central city--is also undergoing change. Blight, delinquency, social ills, violence--these stand in dreary contrast to high- rise luxury apartments, efficient new office buildings, huge public housing projects, and the ever-widening freeways linking the center with its semiautonomous satel- lite communities. Our people are mobile as no people before them--making the Nation their home. They are increasingly interdependent. And with automation, the market for muscle and sheer strength is waning--the demand for skill, technique, and knowl- edge booming. The United States has come a long way in promoting the gencral welfare, but each generation must renew its wellsprings, think through individually, and discuss in groups, small and large, the validity of present policies on issues con- fronting the Nation, to reassess where we have been, to determine the directions we want to take, and how we may go to reach those objectives. Through New Directions we hope to evoke such thinking. Comments and suggestions for further use and development of this publication will be appreciated. Wilbur J. Coen Assistant Secretary (for Legislation) U. S. Department of Health, Education, and Welfare NEW DIRECTIONS in Health, Education, and Welfare June 1963 Page TABLE OF CONTENTS PART I: NEW DIRECTIONS FOR NATION AND COMMUNITY Five 1963 Special Presidential Messages to Congress . . o.oo vv vo vee eee eee eee 3 The First Decade: Change and Challenge, Secretary Anthony J. Celebrezze. « « vo vv ov ove eee enn 20 The Tenth Anniversary of the Department of Health, Education, and Welfare, Wilbur J, Cohen and Joseph W. Kappel « « « 4 © 4 os 4 6.5 6.0 5% 245 tv sn ws % ts 202 swsmemen sm vsssssn 22 Community Needs and Goals for Community Services, Irvin Walker and Eugenia Sullivan « « « « «vv ov vv uur 46 PART Il: CHANGING POPULATION AND CHANGING NEEDS Trends in Marriages, Births, and Population, Anders Lunde, Carl Ortmeyer, and Earl Huyck + « « «ov ov ov un. 57 Investment in Human Resources, Council of Economic AdViSers « . « «uve vv ue eee ee eee ea 71 Public and Private Expenditures for Health, Education, and Welfare, Wilbur J. Cohen and Ida C. Merriam . . «viv i i i i i it tt ete tt ete eet ee ete eee ee eee eee 79 PART Ill: CURRENT AND EMERGING ISSUES AND OPPORTUNITIES HEALTH Environmental Air Pollution, Roy Head and Luther W. Stringham . . «vv vv vv ett t ee eee ee ee ee ee eee eee 91 Water Resources and Pollution Control, Helen E. Martz and Earl E. Huyck + « vv vv vv eee eee eens 99 Illness Chronic Conditions and Disability, Charles S. Wilder and Eugenia Sullivan. . . «vv vv vv vv vee eee en 112 Mental Retardation, Luther W. Stringham « « «vv vv vv i ttt ee ee eee ee eee eee eee eee 116 Mental Retardation: Report of the President’s Panel, Leonard W.Mayo. . . «vv vv vv viv v ven nn. 127 Manpower and Facilities Manpower for Medical Research, Herbert H. Rosenberg and Luther W. Stringham + « « «vv vv vv vee uns 136 Health Facility Construction, Jack C. Haldeman and Luther W. Stringham . . «voc vv ove eee en 146 Costs and Insurance Hospital Costs, 1946-1961, Eugenia Sullivan and Earl E. Huyck « « vv «vv tev eet ee ee eee eee een 156 Hesplial tngurance and Proportion of Bill Paid by Insurance, Augustine Gentile and Earl E. Huyck « + - « 159 EDUCATION Educational Enrollments, 1962-63, Kenneth A. Simon « « «cc veo tov ooo oot ote oonennnnnsenns 165 Educational Attainment and Family Background, Florence Campi - . . «cc cv ivi viii 168 Limited Educational Attainment: Extent and Consequences, Edward W. Brice and Earl E. Huyck . ..... 170 Library Services, Wilbur J. Cohen and John Lorenz . . . «cov ov i vieennaneaeee cnt nnnnn 178 Developments Under the National Defense Education Act. . o.oo cvveviiniie eee 188 School Assistance in Federally Affected Area . . «ov cv vii ie iii iii 192 WELFARE AND INCOME MAINTENANCE The Older Population, Eugenia Sullivan « «oc cv oo vc uae ete e one coe aeous toanenensnnsas 197 New Horizons for the Aged, Wilbur J. Cohen and Donald P. Kent . . . «cco viii iin iinennnennn 210 Medical Care for the Aged Under Public Assistance, Helen E. Martz . . . . . «cc. oii ition 224 Juvenile Delinquency, Donald M. Pilcher, Leonard W. Stern, and I. Richard Perlman .. . . ............ 236 From Work Relief to Rehabilitation Through Work and Training, Helen E. Martz and Earl E, HUyck «. « « « «cc tt tt i et a a ao oa oo a a os aa os ooo oso osec oe 250 See pages at the end of this document for a description of the relationship between New Direc- tions. . .and the monthly Health, Education, and Welfare Indicators and its annual supplement, Health, Education, and Welfare Trends; the annual Handbook on Programs. . .and its supplement, the annual Grants-in-Aid and other Financial Assistance Programs. . . These together comprise the ““5-Star Family of Publications’’ prepared by the Office of Program Analysis under the supervision of the Assistant Secretary (for Legislation), U. S. Department of Health, Education, and Welfare. Pages 260-261 of this document contain sample pages of the central statistical core of the monthly Indicators and the annual Trends. Feature articles carried each month in Indicators were brought together to form New Directions. vi PARTI NEW DIRECTIONS FOR NATION AND COMMUNITY i 8 o = r Ll h ’ 0d ' = } hy, 3 - i ys . i | on a | } - = : - > RE = ig g = aE == nn = {= = Be le oo oo B oo jn SR : rie - a=" fa. = i joa _ rie LH parr nN lente —_ AE at —— = - pn . 7 a ala . = = . FIVE 1963 SPECIAL PRESIDENTIAL MESSAGES TO CONGRESS o First Special Messages on Youth, the Elderly, Mental lliness and Mental Retardation eo New Approaches to Health and Education Proposals for Federal action to further improve the Nation's health, education, and welfare were made by President John F. Kennedy in five 1963 special messages sent to Congress in January and February. New approaches were emphasized in the health and education messages. Mental illness and mental retardation, youth and the elderly were singled out for the first time in history as subjects of special presidential messages. The President emphasized the stimulatory role of the Federal government in giving new directions to policies and programs and in strengthening the historic and unique partnership between the Federal government and the State and local governments, private agencies and institutions. The special messages are summarized here in the order in which they were sent to Congress; the President's recommendations for legislative action are given particular attention. Charts developed by the Department of Health, Education, and Welfare are included to give a quick picture of the existing situation and needs as pointed out by the President in the text. Population Trends, 1935 - 1975 Millions of Persons Millions of Persons 250 250 A i 1 Lie da i Akamai hkl hd PE A 1935 1940 1945 1950 1955 1960 1965 1970 1975 Heslch, This summary was developed by the Office of the Assistant Secretary (for Legislation) in conjunction with the agencies of the Department of Health, Education, and Welfare. The five 1963 special messages are contained in Documents of the House of Representatives, 88th Congress, lst Session as follows: (1) "Program for Education," January 29, No. 54; (2) "Mental Ill- ness and Mental Retardation,” February 5, No. 58; (3) "Health Program," February 7, No. 60; (4) "Our Nation's Youth," February 14, No. 66; and (5) "Elderly Citizens of Our Nation," February 21, No. 72. Health, Education, and Welfare Indicators, May 1963 PROGRAM FOR EDUCATION President Kennedy outlined his 1963 program for Federal aid to education in a special message to the Congress on January 29. The Educational Challenge "A free nation can rise no higher than the standard of excellence set in its schools and colleges. Ignorance and illiteracy, unskilled workers and school dropouts--these and other failures of our educational system breed failures in our social and economic system: delinquency, unemploy- ment, chronic dependence, a waste of human resources, a loss of productive power and purchasing power and an increase in tax-supported benefits. Goals for the Nation "First, we must improve the quality of instruction provided in all of our schools and colléges. We must stimulate interest in learning in order to reduce the alarming number of students who now drop out of school or who do not continue into higher levels of education. This requires more and better teachers--teachers who can be attracted to and retained in schools and colleges only if pay levels reflect more adequately the value of the services they render. It also requires that our teachers and in- structors be equipped with the best possible teaching materials and curric- ulums. "Second, our educational system faces a major problem of quantity-- of coping with the needs of our expanding population and of the rising educational expectations for our children which all of us share as parents. Nearly 50 million people were enrolled in our schools and colleges in 1962-- an increase of more than 50 percent since 1950. By 1970, college enrollment will nearly double, and secondary schools will increase enrollment by 50 percent. "Third, we must give special attention to increasing the opportuni- ties and incentives for all Americans to develop their talents to the utmost--to complete their education and to continue their self-development throughout life. This means preventing school dropouts, improving and ex- panding special educational services, and providing better education in slum, distressed, and rural areas where the educational attainment of stu- dents is far below par. It means increased opportunities for those stu- dents both willing and intellectually able to advance their education at the college and graduate levels. It means increased attention to vocation- al and technical education, which have long been underdeveloped in both effectiveness and scope, to the detriment of our workers and our technolog- ical progress. Millions of Students School-Year Enrollments Millions of Students 75 : [P) . ¥ ~~ 60 Higher Education ” Pa 60 // Secondary (Grades 9-12) a, 3 Bs Elementary (Kindergarten - grade 8) % yy — % — us -— 30 —— 0 15: prom — 15 0 0 1963 19 1973 School Year Ending Health, Ed i sad Welfare Trends The Federal Government's Responsibility "Our concern as a Nation for the future of our children--and the growing demands of modern education which federal financing is better able to assist--make it necessary to expand Federal aid to education beyond the existing limited number of special programs. "Yet...the Federal government cannot provide all the financial assist- ance needed to -solve all of the problems mentioned. Instead of a general aid approach that could at best create a small wave in a huge ocean, our efforts should be selective and stimulative, encouraging the States to re- double their efforts." The Comprehensive Approach In presenting the entire educational program as one piece of legisla- tion, the President cited three guidelines that had shaped the program: an appraisal of the entire range of educational problems, a selective appli- cation of Federal aid, and more effective implementation of existing laws. He said, "To enable the full range of educational needs to be considered as a whole, I am transmitting to the Congress with this message a single, comprehensive education bill--the National Education Improvement Act of 1963. For education cannot easily or wisely be divided into separate parts. Each part is linked to the other. The colleges depend on the work of the schools; the schools depend on the colleges for teachers; vocational and technical education is not separate from general education." 5 In broad categories the President's legislative recommendations would: Expansion of Opportunities for Individuals in Higher Education e Extend the National Defense Education Act student loan program, liberalize the repayment forgiveness for teachers, raise the ceiling on total appropriations and eliminate the limitation on amounts available to individual institutions. « Authorize a supplementary new program of Federal insurance for commercial loans made by banks and other institutions to college students for educational purposes. . Establish a new work-study program for needy college students unable to carry too heavy a loan burden, providing up to half the pay for students employed by the colleges in work of an educational character--as, for example, laboratory, library or research assistants. + Increase the number of National Defense Education Act fellowships to be awarded by the Office of Education from 1,500 to 12,000, including summer session awards. « Authorize a thorough survey and evaluation of the need for scholar- ships or additional financial assistance to undergraduate students so that any further action needed in this area can be considered by the next Congress. e Expand the number of National Science Foundation fellowships and new teaching grants for graduate study from 2,800 in 1963 to 6,700 in fiscal 196k, through budget increases already before the Congress. Expansion and Improvement of Higher Education « Propose a program to provide loans to public and nonprofit private institutions of higher education for construction of urgently needed academic facilities. « Authorize a program of grants to States for construction of public community junior colleges. « Propose a program of grants to aid public and private nonprofit insti- tutions in the training of sciemtific, engineering, and medical technicians in 2-year college-level programs, covering up to 50 percent of the cost of construction and equipping as well as operating the necessary academic facilities. « Strengthen the National Science Foundation matching grant program for institutions of higher education to expand and improve graduate and under- graduate science facilities. « Authorize Federal grants to institutions of higher education for library materials and construction, on a broad geographic basis, with pri- ority to those most urgently requiring expansion and improvement. 6 e Enact a Federal grant program administered by the Department of Health, Education, and Welfare for the development and expansion of new graduate centers. Increase funds requested in the 1964 budget for expansion of the National Science Foundation program of science development grants. e Extend and expand the current modern foreign language program aiding public and private institutions of higher learning. Improvement of Educational Quality « Expand the National Science Foundation science and mathematics course materials program and the Office of Education educational research programs. * Broaden the Cooperative Research Act to authorize support of centers for multipurpose educational research, and for development and demonstra- tion programs; and broaden the types of educational agencies eligible to conduct research. « Expand the National Science Foundation program for teacher training institutes in the natural sciences, mathematics, engineering, and social sciences in order to provide for upgrading the knowledge and skills of 46,000 teachers. e Grant: (1) broader authority for teacher institutes financed by the Office of Education, now restricted to school guidance counselors and language teachers, to other academic fields; (2) authority for a program of project grants to help colleges and universities improve their teacher preparation programs by upgrading academic courses and staff, by encouraging the selection and retention of their most talented prospective teachers, and by attracting and training teachers from new sources such as retired military personnel or women whose family responsibilities permit them to teach; and (3) authority for training grants through colleges and universities for teach- ers and other education personnel requiring specialized training, with par- ticular emphasis on the training of teachers of the mentally retarded and other handicapped children, teachers of gifted or culturally deprived children, teachers of adult literacy, librarians, and educational researchers. Strengthening Public Elementary and Secondary Education o Provide a L-year program to assist States in undertaking through their own State plens selective and urgent improvements in public elementary and secondary education including: (1) increasing starting and maximum teacher salaries and increasing average teacher salaries in economically disadvantaged areas; (2) constructing classrooms in areas of critical and dangerous shortage; and (3) initiating pilot, experimental, or demonstration projects to meet special educational problems, particularly in slums and depressed rural and urban areas. Extend the National Defense Education Act programs in guidance counseling and testing and for purchasing mathematics, science and modern foreign language equipment which contribute to improving the quality of elementary and secondary education. * Provide a 4-year continuation of those portions of the school assist- ance for federally affected area laws which expire June 30, 1963. Vocational and Special Education * Provide funds which would permit doubling the number of workers to be trained by the Manpower Development and Training Act programs. Expand the scope and level of vocational education programs supported through the Office of Education by replacing the Vocational Education Act of 1946 with new grant-in-aid legislation aimed at meeting the needs of indi- viduals in all age groups for vocational training in occupations where they can find employment in today's diverse labor markets, and provide employment and training opportunities for unemployed youth in conservation and local public service projects. Continuing Education * Authorize Federal grants to States for expanding university extension courses in land-grant colleges and State universities. * Authorize a program to assist all States in offering literacy and basic education courses to adults. Amend the Library Services Act by authorizing a 3-year program of grants for urban as well as rural libraries and for construction as well as operation. MENTAL RETARDATION IS A CONDITION CHARACTERIZED BY THE FAULTY DEVELOPMENT OF INTELLIGENCE The DEGREE of retardation varies greatly among individuals: 60,000-90,000 persons are PROFOUNDLY or SEVERELY retarded 300,000-350,000 persons are MODERATELY retarded 5-6 million persons are MILDLY retarded The NUMBER of mentally rétc ded persons is increasing: 126,000 infants are born each year who will be mentally retarded Without decisive advances the number of mentally retarded persons will increase by ONE MILLION in the 1960's The CAUSES of mental retardation are not fully known: 15-25% of the cases involve specific diseases or brain damage 75-85% of the cases are caused by incompletely understood factors 8 MENTAL ILLNESS AND MENTAL RETARDATION In a special message to Congress on February 5, 1963, the President proposed a bold new approach to the twin problems of mental illness and mental retardation that are of such tremendous size and tragic impact. Too long have they been considered problems unpleasant to mention, easy to post- pone, and despairing of solution. The proposed Program, designed to use Federal resources to stimulate State, local, and private action, encompasses prevention, treatment, rehabilitation, research and manpower development. A NATTONAL PLAN FOR MENTAL HEALTH The President directed the Secretary of the Department of Health, Education, and Welfare to explore steps for encouraging and stimulating the expansion of private voluntary health insurance to include mental health care. He made the following legislative recommendations as initial develop- ments in a national program for mental health that within a decade or two could halve the number of patients now under custodial care: Community Mental Health Centers * Authorize grants to the States for the construction of community mental health centers and short-term project grants for the initial staffing of such centers. ° Appropriate $4.2 million for mental health planning grants. Research and Manpower + Appropriate $66 million for training purposes to increase the availa- bility of trained manpower for research and other mental health programs. Thousands of Patients State and Local Government Mental Hospitals Thousands of Patients] Improved Care in State ah 1 Mental Institutions TT 500 | 5° ° Appropriate $10 million for the er 1° support of projects to improve the qual- 0 °° ity of care in State mental institutions Admissions —1200 and to provide in- service training for 100 personnel in these institutions. 0 ad FN NE! clomid 0 1945 1950 ©1955 1960 1965 Health, Edu sad Welfare Treads A NATIONAL PROGRAM TO COMBAT MENTAL RETARDATION The President pointed out the complex and unique nature of the problem of mental retardation and the need for a broad approach that would meet the medical, psychological, social, educational, and vocational needs of the mentally retarded. He then outlined the action necessary to implement such a program: Prevention « Provide project grants to stimulate the development of comprehensive maternal and child health care service programs, directed primarily to families in high risk groups. « Double the authorization for Federal grants for maternal and child health and crippled children's programs from the present $25 million to $50 million for each program by 1970. « Commit at least 10 percent of the proposed aid to elementary and second- ary education to special project grants to improve educational opportunities in slum and distressed areas. Community Services « Provide special project grants for financing State reviews of needs and programs in the field of mental retardation. e Permit up to 18 months of rehabilitation services for mentally retarded persons for the determination of vocational rehabilitation potential. . Provide financial assistance in the construction, equipping, and staffing of rehabilitation facilities and workshops for the mentally retarded. e Authorize matching grants for the construction of facilities for the mentally retarded. o Appropriate initially $5 million for project grants to upgrade the quality of residential services in State institutions. Research oe Authorize funds for the construction of centers for research in human development, including the training of scientific personnel. « Expand the authority of the Children's Bureau for engaging in .research in maternal and child health and crippled children's services. 10 HEALTH PROGRAM Addressing Congress on February 7, 1963, President Kennedy ranged broadly over areas affecting our Nation's health that "require serious and sustained attention." These areas include: teaching facilities for doc- tors, dentists, and nurses; encouraging group practice and health research; planning grants and construction aid for health facilities; controlling air pollution; bringing together environmental health and community health func- tions into bureaus; cooperating in community and international health serv- ices; strengthening and improving vocational rehabilitation; and ensuring the safety of food, drugs, devices, and cosmetics. To these ends the President made legislative recommendations which would: Education for Physicians and Dentists Provide Federal matching grants for the construction of new, and the expansion or.rehabilitation of existing, teaching facilities. °* Provide Federal financial assistance for students of medicine, den- tistry, and osteopathy. Nurses' Education e Provide financial assistance to Graduates of basic professional expand teaching facilities for nurses nursing programs training. ° Provide financial assistance to students of nursing. ¢ Initiate new and improved pro- grams for the support of graduate nurs- ing education. * Initiate new programs and expand current programs of research directed toward improved utilization of nursing personnel. Encouragement of Group Practice ° Authorize a five-year program of Federal mortgage insurance and loans to help finance the cost of constructing and equipping group practice facilities for medicine and dentistry. Health Research » Increase appropriations for sup- port of the National Institutes of Health. 11 Health Facility Planning Grants « Authorize planning grants to public and nonprofit organizations to assist in developing comprehensive areawide plans for, the construction and operation of all types of health facilities. Aid for Construction of Hospitals and Nursing Homes » Extend the 16-year-old Hill-Burton program for five years, but modi- fied to authorize (1) a new program of financial assistance for modernizing or replacing hospitals and other health facilities, and (2) increased appro- priations for nursing homes. Millions of Dollars Hospital Construction by Type of Financing Millions of Dollars 180 (Current. Dollars) 180 150 150 & 120 Total Hospital Construction 120 TN 90 Total Non-Fe eralzs*t 90 sf NY -’ cer” edd ~~" -~ "\ 2) NS Sede a Without Federal Aid __/ ~~ 60 = Nt 60 ~~ n | Hill-Burton Sponsor's Share NN —/—— IB 30 I aii. Hi]1-B Federal pi — -Burton er - —, on ———— | a Tm —— ——— — arene Time . ees — = Direct Federal 0 Leman drm mete Tee ee ee eee 0 1958 1959 1960 1961 1962 1963 Health, Education, and Welfare Indicators Air Pollution Control Authorize the Public Health Service to: » Engage in a full investigation of the causes, effects and control of air pollution. °e Provide financial stimulation to States and local air pollution control agencies. e Conduct studies on air pollution problems of interstate or nation- wide significance. °* Take action to abate interstate air pollution. Environmental Health * Grant authority to the Surgeon General to bring environmental health functions together in one bureau. 12 Community Health Services e Grant authority to bring all community health activities of the Public Health Service together in one bureau. ¢ Provide funds to initiate programs under both the Vaccination Assistance Act and the Migrant Health Act passed last year. International Health Provide funds under the 1964 budget proposal to initiate efforts to eradicate the yellow fever-carrying mosquito from the United States as pledged in accordance with the policy of the Pan American Health Organization to eliminate yellow fever in this hemisphere. Vocational Rehabilitation ° Increase funds for, and otherwise strengthen and improve, the State- Federal program of vocational rehabilitation. Thousands Vocational Rehabilitation Thousands 30 — - - RRR eres 7 30 i A i ii Moa New Ref! fir no rd i3 2s ew Re ox ] EY wi Oli essen 5 i # K VY vou i rat ~ AS ¥ ¥ o, «© A / : ; }, 2, A 3 ° % ; [AY] 20 ii “ i s et %,S LF 20 A W <. 15 i 15 . ~ ro Cases Accepted iN J \ vy | ANT NN nS A ~ 1A nN A A \ nd Vv Vv MV \ IP IA WEEDS . AY 10 ’ vy > / J y A AT Persons Rehabilitated 0 Metered aad ada iinet Lo 0 1958 1959 1960 1961 1962 1963 Health, Education, sad Welfare Indicators Food, Drugs, Devices, and Cosmetics o Extend and clarify inspection authority ° Require cosmetics to be tested and proved safe before marketing. Require Manufacturers of therapeutic devices to assure the reliability of their products, and require proof of safety and effectiveness before such devices are put on the market. Extend requirements for label warnings to include hazardous household articles. 13 OUR NATION'S YOUTH The Presidential Message on Our Nation's Youth, sent to Congress on February 14%, 1963, is the first special Message on Youth by a President of the United States. Dwelling initially on the great expansion of the youth population of our Nation and the consequent economic, social, and educational problems, the Youth Message outlines five specific programs designed to im~- prove opportunities for young people in Problems of American Youth the United States. The 30-percent increase in the birth rate between the 1930's and 1947 contributed to the increase in the number of youths under 20 from 46 million in 1945 to 70 million in 1961 and an increase relative to the total popula- tion from 33% to 39 percent. The school population grew correspondingly. This year the number of persons 16 years of age will be more than a million greater than last year. 22.3 MILLION YOUTH WILL NEED PREEMPLOYMENT TRAINING IN THE 1960'S Youth unemployment is characteristic of the youth population increase. Unemployment among work- ers today is 2% times the national unemployment av- erage and is even higher among young Negroes and those without a high school diploma. During the 1960's some 75 million 7.5 MILLION LESS THAN A HIGH SCHOOL EDUCATION 10.1 MILLION [+7 mon | HIGH SCHOOL GRADUATES WITHOUT COLLEGE TRAINING 22.5 MILLION HIGH SCHOOL GRADUATES students will drop out of high school. 30 MILLION AMERICAN YOUTH IN THE 1960'S Thousands of Cases Juvenile Court Delinquency Cases Thousands of Cases 900 Youth delinquency Including Traffic = Lame F Excluding Traffic is another problem of vital concern. In the last decade, —— Rate Per 1,000 Population 10 Through 17 Years of Age 1940 1946 1952 1958 = Healrh, Education, sad Welfare Treads Juvenile delinquency cases brought before the courts more than doubled, and record- ed arrests of youth increased 86 percent. 0 1962 1h Programs for Youth Opportunity To counteract these serious problems and to provide greater opportuni=- ties for all young people able to take advantage of them, the Administration has developed and proposed specific programs which are outlined in the Youth Message: (1) Under the Manpower Development and Training Act of 1961 the Federal Government is assisting State and local officials to provide additional train- ing for out-of-school youth at the community level. The 1,900 local public employment offices have accelerated. their programs of counseling, testing, and placement services for youth workers. (2) The Youth Employment Act of 1963, now before the Congress, would provide employment initially for 15,000 young men in youth conservation camps. Jobs in local public service employment would be provided for up to 50,000 young men and women annually in public and private agency employment. (3) The proposed National Service Corps would provide an opportunity for as many as 5,000 American citizens 21 and over to work in voluntary serve ice programs in all parts of the Nation. This "domestic peace corps" would provide an opportunity for skilled and dedicated people to work on some of our most difficult and critical problems such as mental retardation, with mi- grant workers and their children, with delinquent youth, and in helping young students who are having difficulties in our crowded schools in urban and slum areas. (4) The Peace Corps has already demonstrated its effectiveness and usefulness overseas. In the two-year period of its operation almost 45,000 American men and women, the majority of them young people, have volunteered their services. In January of this year there were 4,000 volunteers 30 years old or younger in training or in service in Ui countries. (5) The Juvenile Delinquency and Youth Offenses Act of 1961 set in motion a new Federal program to develop comprehensive community programs for the prevention of delinquency. In 16 cities demonstration and planning projects are now underway. Agencies and institutions have been brought to- gether to develop a community-wide program of juvenile delinquency preven- tion. At 31 universities training institutes give specialized training to governmental and youth agency officials working with young people and counter- ing juvenile delinquency. The President's Youth Message takes note of the fundamental importance of a good educational opportunity for every American youth and the necessity of good health and physical fitness. The President's Council on Youth Fitness has given leadership and direction to programs--during the 1961-62 school year 56 percent of the 108,000 public schools strengthened their physical education programs and some 2,000 private and church-related schools offered Physical education for the first time. 15 ELDERLY CITIZENS OF OUR NATION On February 21, President Kennedy became the first President ever to send to the Congress a special message relating to our elderly citizens. The President pointed out that the presence today of 17% million people aged 65 years and over--nearly one-tenth of our total population and increasing by 1,000 per day--reflects a profound change in the age composition of our Nation. "This increase in the life span and in the number of our senior citizens pre- sents this Nation with...the opportunity to draw :.upon their skill and sagacity and the opportunity to provide the respect and recognition they have earned." But he pointed out, through certain "sobering statistics,” that there are attend- ant problems. Years Life Expectation in the United States Years 80 80 ~ 60 N\ 60 At Birth \ Lo \ 40 20 \ 20 NN At Age 65 0 0 Men Women Men Women 1900 1961 Health, Educstion, snd Welfare Trends The average annual income received by aged couples is half that of younger two-person families; almost half of those over 65 living alone receive $1,000 or less a year. A far greater proportion of senior citizens than of younger citizens live in inferior housing. Older people are sick more frequently and for more prolonged periods than the rest of the population; yet only half of those aged 65 and over have any kind of health insurance. The President proposed 36 specific points looking toward improvement of these conditions and the translation of the scientific achievement of longer life into effective human achievement. The result of these recommendations-- legislative and executive--if carried out, would be to: Health e Provide a hospital insurance program for senior citizens under the social security system. 16 e Improve the medical care provision under public assistance through (1) encouraging those States which have not already established programs for the medically indigent aged to do so, and (2) strengthening the program in those States where existing programs are incomplete. ° Strengthen the basic welfare law authorizing medical care for persons on old-age assistance by providing medical protection to the indigent at least equal to that provided for those who are only medically indigent. ° Strengthen the program also through elimination of the 42-day limit on medical care in a general hospital provided for persons suffering from mental illness or tuberculosis. ° Increase the Hill-Burton appropriation authorization for high quality nursing homes from $20 million to $50 million. . Increase medical facilities and services through: (1) enactment of previously recommended legislation authorizing Federal matching funds for con- struction of new, and expansion or rehabilitation of existing, teaching facili- ties for the medical, dental and other health professions; (2) Federal finan- cial assistance for students of medicine, dentistry, and osteopathy; (3) revi- sion of the Hill-Burton hospital construction program to enable hospitals to modernize the rehabilitate’ their facilities; and (4) financial assistance for the construction and equipping of group-practice medical and dental facilities. . Expand Food and Drug Administration consumer protection for the elderly by extending provisions of the Food, Drug and Cosmetic Act of 1938: (1) to include testing of the safety and effectiveness of therapeutic devices; (2) to extend label warning requirements to include household articles subject to the Act; (3) to extend adequate factory inspection to foods, over-the counter drugs, devices, and cosmetics; and (4) to provide additional information to consumers to enable them to make more informed choices in the purchase of foods and drugs. Medical Care Prices, 1946-1962 Index 1957-59=100 Index 1957-59=100 oto care | Potctns resctgtions oti patty 180 120 C558 ER a T 90 N 9 . NIN . . NN . 0 1 1 1 1 iL i 5 0 1 NN 1 1 1 2 1 1 0 1946 1062 1946 1962 1946 1962 ] Health, Education, and Welfare Treads 17 Education and Use of Lelsure Time e Provide a basic-education attack upon illiteracy. e Increase support of adult education, making available at reasonable tuition fees those courses of interest to the elderly. e Extend library services for the elderly in particular. e Stimulate the use of older people in teacher preparation and programs as part of realizing their unutilized potential. Employment Opportunities o Require each Federal agency--and urge all employers, public and private-- to honor fully both the spirit and letter of official Federal policy to evaluate each older applicant or employee on the basis of ability rather than age. + Increase funds for (1) the Federal-State Employment Service to strengthen and expand counseling and placement services and (2) training programs under both the Manpower Development and Training Act and the Area Redevelopment Act. « Establish a new 5-year program of grants for experimental and demonstra- tion projects to stimulate needed employment opportunities for the aged. * Make a searching reappraisal through the President's Council on Aging in consultation with private organizations and citizens of employment problems for the aged. * Provide opportunities for voluntary services by older persons in the National Service Corps and the Peace Corps. P t of Populati v .. Percent of Population Ee 5 Sp °" Aged Recipients of Social Security and Public Assistance Benefits 65 and em 100 100 80 Tocoecereq ® ” ’ ” yl 60 ~~ 60 0ld-Age and Survivors Insurance Beneficiaries About one-third of old-age assistance recipients--and ko one-half of those now coming | Lo on the rolls--are also social security beneficiaries. — ——) 20 20 Co ————— 0ld-Age Assistance Recipients [e] 1 1 1 1 1 1 1 1 1 J 1 1 i 1 } 4 ok 1 1 1 1 L 4 1 0 1940 1945 1950 1955 1960 1965 1970 Health, Education, sad Welface Treads 18 Welfare and Income Maintenance * Increase the maximum taxable wage base on which Social Security bene- fits are computed from $4,800 to $5,200 a year, and reexamine the entire relationship between benefits and wages (through the Advisory Council on Social Security Financing to be appointed by the Secretary of Health, Education, and Welfare). Improve old-age assistance through reduction of residence requirements to a maximum of one year by 1970, and permit Federal participation in protective Payments made to a third party in behalf of needy aged individuals. e Authorize, as a condition for receiving Federal grants for old-age assistance, the establishment and maintenance in State plans of standards of health and safety for rental housing for old-age assistance recipients. Reduce and equalize the tax burdens of older persons, through a number of provisions in the Administration's tax reduction and reform measures. Housing e Provide additional funds for the direct loan programs for senior housing and for rental housing for the elderly in rural areas. » Emphasize construction of group residence facilities with gecess to appropriate health and social services for older people who require assistance In certain aspects of daily living. Extend eligibility for moderate income housing to single elderly persons. * Develop a program to assist older citizens with the modernization, reha- bilitation, or sale of their individually owned homes. Community Action ° Assist States to assign specific responsibility for stimulating and coordinating programs on aging in Each State government and in every locality of 25,000 or more population. o Provide a 5-year Federal grants program to assist the States and commu- nities in developing comprehensive community programs for the elderly through grants for planning, research, demonstration and training, and for the con- struction of multipurpose recreation and activity centers. 19 THE FIRST DECADE: CHANGE AND CHALLENGE This year marks the tenth anniversary of the Department of Health, Education, and Welfare--the newest Federal agency to be represented in the President's Cabinet. However, the responsibilities it bears for the well- being of the American people date back to the early years of our Republic. They began in 1785, when the Congress of the Confederation made grants of public lands to the States for public schools. They were added to in 1798, when the Fifth Congress established the Marine Hospital Service--forerunner of today's Public Health Service. In 1867 the Federal Office of Education was established; in 1907 the Food and Drug Administration began as the Bureau of Chemistry in the Depart- ment of Agriculture; in 1912 the Children's Bureau was established; in 1920 the predecessor of the present Vocational Rehabilitation Administration began its important work; and in 1935 the Social Security Board was organized. All these agencies were brought together in 1939 under the framework of the Federal Security Agency, and 1k years later the Agency was given Cabi- net status when it became the Department of Health, Education, and Welfare. 20 In this chronology of the Department's growth, we can trace the Nation's growing recognition of the need for Federal participation in promoting the general welfare of the American people. Through periods of prosperity and de- pression, through civil strife and world conflict, the Federal Government has shared in the national concern for the well-being of every citizen. We are now in an era of change and challenge which in many ways eclipses those critical periods of our past. We are in the midst of a technological revolution which is changing the pattern of life and work of the American people. As our national strength and prosperity have increased, we have grown more and more aware of pressing problems within our society which cry out for solution--problems of great magnitude and complexity that are beyond the re- sources of the individual and his local snd State governments. Some of these problems have long been with us and require solution even more urgently today; some are the outgrowth of the technological forces which are altering our society; others have arisen as a natural consequence of the higher human expectations of larger numbers of citizens. In education, for example, we have a shortage of facilities and well- trained teachers at the same time that we face increasing demands for more schooling for more people. We have millions of young people and millions of adults whose lack of adequate education prevents them from enjoying a full meas- ure of the Nation's prosperity and from making their full contribution to society. Our aged men and women, those in the lowest income group and most subject to illness, have tragically inadequate insurance against the high cost of hospi- tal care and related health services. Other problems in our society represent an appalling waste of human lives and human potential: mental illness and mental retardation, drug addic- tion, accidents, juvenile delinquency. Increasingly we are concerned with problems of air and water pollution, and the proliferation of chemicals in the production and processing of foods. In the following pages are summarized the progress this Department has made during the past decade in carrying out its responsibilities for the well- being of the American people. As we review the successes of the Department's first ten years, let us look forward to a second decade of helping to make available to all citizens full opportunities for the development of their talents and abilities. These are our most precious resources--our hope for the future. Noh Secretary of Health, Education, and Welfare THE TENTH ANNIVERSARY OF THE DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Wilbur J. Cohen and Joseph W. Kappel Creation of the Department of Health, Education, and Welfare on April 11, 1953, culminated more than 30 years of effort by citizens who believed that the Federal government needed an agency of cabinet status to carry out effectively its constitutional responsibility for "promoting the general welfare." Only by such action could the health, education, and welfare interests of the American people receive their due considera- tion at the policy-making level of the President's Cabinet. The changing concept of the Federal government's responsibility with regard to the general welfare over a hundred year period is evident when one contrasts the establishment of the Department of Health, Education, and Welfare in 1953 with the veto in 1854 by President Pierce of Dorothea Dix's bill for a grant of land to support the indigent curable and incur- able insane in the United States. Despite "the deep sympathies of (his) own heart," the President vetoed this bill on the grounds that it was not proper nor constitutional for the Federal government to provide "for the care and support of all those....who, by any form of calamity, become fit objects of public philanthropy." Much has happened since that veto message was written. The importance of the change in viewpoint concerning the Federal government's responsibility is demonstrated by the overwhelming, bipartisan support in the Congress when the legislation creating the Department in 1953 was enacted. After passage in the House by a vote of 291 to 86, it was approved by a voice vote in the Senate. Senator Taft on that occasion said: "I eam very much pleased that we have finally reached our objective. We have sought for a long time to give to the three agencies affected representation in thie Cabinet, the policy-making section of the Government, immediately under the President. These activities of the Federal Government are tremendously important to the welfare of the Nation, although the Federal Government does not under - take to assume primery direction in the three fields." Senator Humphrey stated that: "....the plan meets a long felt need for participation by the Federal government in the services of health, education, and welfare. I concur in the view expressed by the Senator from Ohio (Mr. Taft) that the essential function of the proposed Department would be the carrying out of present programs, which are, in the main, State-aid programs, and represent mechanisms for cooperation between the Federal government, State governments, and local institutions and govern- ments in the field of health, education, and welfare." Mr. Cohen is the Assistant Secretary for Legislation and Mr. Kappel is a member of his staff as a Program Analysis Officer. Health, Education, and Welfare Indicators, April 1963 22 Demographic and Economic Background Any account of the Nation's programs of health, education, and welfare during the past ten years can be properly assessed only when viewed against the backdrop of the dramatic growth of our population and economy in recent decades. In the period for which figures are obtain- able most closely matching the ten years of the Department's history, the population increased by an unprecedented 30 million (July 1952 to July 1962). In 1963 the total population had reached 188 million people. In 1962 we had over 17 million persons aged 65 and over, as compared with 13 million in 1952; our school-age population, largely concentrated in the 5 to 19 age group, numbered 52 million in 1962, as compared with 37 million in 1952. In the brief 30 months since the 1960 Census the school- age and younger population (under age 20) increased by over I million, while the adult working age population (20-6k years) increased by over 2 million. Looking ahead to the next decades, a total population of about 250 million persons is estimated by the year 1980. Aside from sheer growth, a remarkable feature of our demographic development in recent decades has been the shift from farm to city. While the population in urban areas increased by 28 million between 1950 and. 1960 to a total of 125 million, the rural population actually declined from 54 million to 53 million. We have become an urban society with problems of health, education and welfare concentrated in urban-suburban areas. The period 1953-1963 has been notable not only for its great increase of population but also for the vast growth of the American economy. The gross national product grew from $365 billion in 1953 to $554 billion in 1962. Personal income increased during this period, and per capita dispos- able personal income rose from $1,582 in 1953 to over $2,000 in 1963. At the same time, there were rises in the cost of living. A significant factor from the standpoint of the programs of the Department of Health, Education, and Welfare has been the unusual increase in the cost of medical care. Whereas the overall consumer price index rose from 93.2 to about 106.0 during the past decade, the index for medical care increased from 83.9 to 115.0. Most important of all, analysis of the medical care index reveals that physician's fees were consistent with the overall increase, and prescriptions and drugs declined somewhat, but the "hospital daily service charge" component rose from 74.8 in 1953 to over 131.0 in 1963. In dollars, this means that hospital care now averages more than $35 a day. This is the most dramatic increase in the consumer price index. 23 Some Significant Developments in Health, Education, and Welfare, 1952-1962 Item 1952 1962 Mental. hospital patients per 100,000 population 389 333Y Paralytic poliomyelitis cases 21,269 7 Hospital expense per patient day $18.35 $34.98 per patient stay $138.73 $267.37 Number of children under age 18 50,200, 000 67,400,000 Elementary and secondary school enrollments 30,600, 0002 46,700,000 College and university enrollment 2,302, 0009 4.600, 0009 Educational expenditures (billions) $11.3 $27.3 Old-age and survivors insurance beneficiaries 5,026,000 18,053,000 OASI payments per retired worker (monthly) $49.25 $76.19 Number of aged 65 and over 13,000,000 17,300,000 Recipients of old-age assistance 2,646,000 2,226,000 Vocational rehabilitants 63,632 102,377 Y g61. g 1951-52. J 1962-63. Total Expenditures for Health, Education, and Welfare The Federal role in health, education, and welfare, substantial as it is, is but one segment of a large national effort to which important contri- butions are made by State and local governments and by private individuals and organizations. All of these activities amounted to a total expenditure, public and private, on health, education, and welfare, of $42 billion in 1953; by 1963 this amount had increased to $101 billion. During this period, the ratio between private and public expenditures remained fairly constant, with $1 in private funds expended for approximately each $2 of public funds. Of the $101 billion* estimated expenditures on health, education, and welfare in 1963: $34 billion was spent for health--25 percent from public funds and T5 percent from private funds; $28 billion was spent for education--80 percent from public funds and 20 percent from private funds; $41 billion was spent for social insurance and welfare--86 percent from public funds and 14 percent from private funds. * The adjusted total of $101 billion eliminates duplication in use of income- maintenance payments (public and private) for private purchase of health or education services. A complete tabulation of these expenditures is presented in the Juneissue of Ir’lcators. For an explanation of what is included in these figures see Ida Merriam's "Social Welfare Expendi- tures, 1960-61," in the November 1962 issue of the Social Security Bulletin. ol The significant roles of the public and private sectors of our society in assuming the financial burden of these enormous expenditures demonstrate the viability of a highly important and indeed unparalleled partnership in our society among private individuals and organizations, their local and State governments, end the Federal government. Major Changes in Programs In 195k, Federal payments to States for the needy and destitute con- stituted T2 percent of the Department's total budget (excluding old-age and survivors insurance benefit payments), whereas they comprise only 51 percent of the Department's budget in 1963. This decrease in comparative importance of programs for the needy during a time when the total budget of the Depart- ment has increased symbolizes the major changes in the Department's programs during its first ten years. During this period, the other programs of the Department have experienced a five-fold expansion from a level of $540 million to $2.5 billion. While almost all of the Department's programs have shared in this growth, the major developments have been in the following three program areas: (1) Medical research programs of the National Institutes of Health; (2) Federal-State assistance Programs in community and environmental health, especially in construction grants for hospitals and sewage treatment plants; (3) Federal aid to elementary, secondary, and higher education under the omnibus provisions of the National Defense Education Act. The key feature of this ten-year period is patently a change of emphasis from amelioration to prevention and rehabilitation. The newly- born Department of Health, Education, and Welfare took over functions which in large measure looked back to problems created by past emergencies or aepressions and other types of crisis, functions designed to help people adversely affected by these problems, whereas the Department of 1963, while making a major effort to improve its "ameliorative" programs, is stressing solutions to present and emerging problems and opportunities. Legislative Developments The shift in emphasis from amelioration to prevention has developed, in large measure, by means of the major legislative changes in the fields of health, education, and welfare that have been enacted over the past ten years. This legislation has effected needed improvements and new directions in basic statutes governing the programs of the Department, and has also established important new programs of Federal assistance to the States and local communities to help solve pressing health, educational and social problems. 25 Social insurance has been strengthened in its role as the first line of defense against econonic insecurity through legislative improve- ments thet have broadened the coverage and strengtnened the financial base of the program, raised benefit levels, and added a new category of benefits for disabled workers and their families. The supportive role of assistance programs has been given new dimensions by the Public Welfare Amendments of 1962, which emphasize preventive and rehabilitation services and the training of competent staff, and provide the States with new tools for naking welfare programs more effective. Extension and improvement of vocational rehabilitation services have grown out of the Vocational Rehabil- itation Amendments of 1954, which strengthened the financial base of reha- bilitation programs and improved resources and facilities through more effective use of available Federal funds. Public Health legislation during the past decade has emphasized the preventive approach through new programs of Federal grants for environmental health control, of grants to promote research toward the prevention and cure of the physicial and mental diseases of man, and of grants-in-aid for the construction of diagnostic centers, rehabilitation facilities, and nursing homes, and by strengthening the existing regulatory powers of the Federal government with respect to food, drugs and cosmetics. The role of education as an indispenseble factor in economic growth and the maximization of individual potential has been given statutory recog- nition in the National Defense Education Act, which has as its purpose "....the fullest development of the mental resources and technical skills of (the Nation's) young men and women." Major HEW Legislative Developments, 1953-1962 During the ten year period, Congress enacted more than 120 pieces of health, education, and welfare legislation, of which 2'( were major new or amended programs. No brief discussion can do justice to the important and many-faceted laws which have been enacted by the Congress during this decade. Even the list which follows, within space limitations, only enumerates the most important. Listed first are enactments which initiated fundamental changes; in a second group are those changes in or additions to existing programs which are of only slightly less importance. 26 Basic Legislation Date Enacted Public Law HEALTH Environmental Air Pollution Control Act of 1955. Provides for studies, investigations, and dissemination of information and for grants and contracts for research, training, and demonstration projects in the field of air pollution control. Federal Water Pollution Control Act Amendments of 1956. Provide for comprehensive programs for water pollution control; interstate cooperation; research, investigation, and training; grants for water pollution control programs; grants for construction of treatment works; enforcement measures against pollution of interstate water, etc. Supplants the Water Pollution Control Act of 1948 (P.L. 845, 80th Congress). Federal Water Pollution Control Act Amendments of 1961. Broaden and strengthen the Federal Govern- ment's pollution abatement powers in this field, provide for a greatly stepped up program of grants for waste treatment works, authorize increased Federal support of State and interstate pollution control programs, provide for an inten- sified program of research into more effective methods of pollution control, and establish the principle of water quality control as a criterion in planning and building Federal reservoirs. Manpower and Facilities Health Amendments Act of 1956. Assists in increas- ing the number of adequately trained professional and practical nurses and professional public health personnel, and in the development of improved methods of care and treatment in the field of mental health. Medical Facilities Survey and Construction Act of 195k. Amends the hospital survey and con- struction provisions of the Public Health Service Act (title VI) to provide grants for surveying the need for, and for constructing, diagnostic or treatment centers, hospitals for the chronically ill and impaired, rehabilitation facilities, and nursing homes. 27 July 14, 1955 July 9, 1956 July 20, 1961 Aug. 2, 1956 July 12, 195k 84-159 84-660 87-88 84-871 83-482 Basic Legislation (cont.) Date Enacted Public Law Health Research Facilities Act of 1956 (adds title VII to Public Health Service Act). Authorizes grants for construction of health research facilities. FOOD AND DRUG Pesticide Amendment of 1954. Amends Federal Food, Drug, and Cosmetic Act with respect to residues of pesticide chemicals in or on raw agricultural commodities. Food Additives Amendment of 1958. Amends the Federal Food, Drug, and Cosmetic Act to pro- hibit the use in food of additives which have not been adequately tested to establish their safety. Kefauver-Harris Amendments ("Drug Amendments of 1962") to Federal Food, Drug, and Cosmetic Act. Broaden factory inspection authority with respect To prescription drugs; require adequate safety and quality controls in drug manufacture; require new drugs to be cleared for efficacy (as well as safety) before they are marketed, permit summary suspension of new-drug clearance if there is an imminent hazard to public health, and otherwise improve new-drug regulation; require batch-by-batch certification of all antibiotics for treatment of humans; require prescription drug advertisements to be more informative; authorize standardization of non- proprietary drug names; require registration of drug manufacturers. EDUCATION Cooperative Research (in Education) Act of 195k. Authorizes contracts or jointly financed co- operative arrangements with universities and colleges and State educational agencies for the conduct of research, surveys, and demonstrations in the field of education. Library Services Act. Authorizes grants to States to promote the further extension of public library services to rural areas without such services, or with inadequate services. July 30, 1956 July 22, 195k Sept. 6, 1958 Oct. 10, 1962 July 26, 1954 June 19, 1956 84-835 83-518 35-929 87-761 83-531 84-597 Basic Legislation (cont.) Date Enacted Public Law National Defense Education Act of 1958. Pro- vides, among other things, for college and university student loans; grants and loans for strengthening elementary and secondary school instruction in science, mathematics, and modern foreign languages; fellowships for graduate study; payments for programs of guidance, coun- seling, and testing in secondary schools; university centers for study in "rare" modern languages and institutes for teachers of modern foreign languages; grants and contracts for research and experimentation in the use of radio, television, motion pictures, and related communications media for educational purposes; grants for area vocational education programs; and grants to improve statistical services of State educational agencies. WELFARE AND INCOME MAINTENANCE Social Insurance and Protection Social Security Amendment of 1954. Amend the Social Security Act and the Internal Revenue Code to extend coverage under the old-age and survivors insurance program, increase the benefits, preserve the insurance rights of disabled individuals, and increase the amount of earnings permitted without loss of benefits. Social Security Amendments of 1956. Provide disability insurance benefits for certain disabled individuals who have attained age 50, reduce to 62 the age on the basis of which benefits are payable to certain women, provide for child's insurance benefits for children who are disabled before reaching age 18, and further extend coverage. Social Security Amendments of 1960. Extend and improve coverage under OASDI and remove hard- ships and inequities, improve the financing of the trust funds, and provide disability benefits to additional individuals under such system, provide grants to States for medical care for aged individuals of low income, amend the public assistance and maternal and child welfare provisions. 29 Sept 2, 1958 Sept. 1, 195k Aug. 1, 1956 Sept. 13, 1960 85-864 83-761 84-836 86-778 Basic Legislation (cont.) Date Enacted Public Law Public Assistance and Child Welfare Public Welfare Amendments of 1962. Assist the States in providing more rehabilitation ser- vices in order to get individuals off the welfare rolls and in developing better trained staffs to render these services; in increasing payments to the aged, the blind, and the dis- abled; in improving the aid to dependent children program, to provide for protective payments, payments on the basis of the unemploy- ment of the parent, community work and training programs, and payments to children removed by court order to foster home care, etc. Provide for gradually doubling the amount authorized for annual child welfare appropriations from $25 million to $50 million per year; for gradually expanding child welfare services throughout each State by July 1, 1975; for special projects for training personnel for work in the field of child welfare, including traineeships; and for earmarking up to $10 million of Federal child welfare funds for day care services. VOCATIONAL REHABILITATION Vocational Rehabilitation Amendments of 95k. Amend the Vocational Rehabilitation Act to promote and assist in the extension and improve- ment of vocational rehabilitation services, provide for more effective use of available Federal funds, and otherwise improve the pro- visions of that Act. July 25, 1962 Aug. 3, 195k 87-543 83-565 Legislation Effecting Major Program Changes Date Enacted Public HEALTH Indian Health Services Act. Transfers the administration of health services for Indians and the operation of Indian hospitals to the Public Health Service. Authorizes the transfer of Freedmen's Hospital to Howard University and the construction of a new and modern teaching hospital for Howard's program of medical teaching, research, and service to the community. 30 Aug. 5, 1954 Sept. 21, 1961 83-568 87-262 Legislation Effecting Major Program Changes (cont. ) Date Enacted Public Law FOOD AND DRUG Federal Hazardous Substances Labeling Act. Regulates labeling of hazardous substances in household-size containers which may cause sub- stantial personal injury or substantial illness. Replaces the Federal Caustic Poison Act, except with respect to foods, drugs, and cosmetics, which remain subject to the latter Act. Color Additive Amendments of 1960. Amend the Federal Food, Drug, and Cosmetic Act to author- ize the use of suitable color additives in or on foods, drugs, and cosmetics, in accordance with regulations prescribing the conditions (including maximum tolerances) under which such additives may be safely used. TRAINING AND RETRAINING Area Redevelopment Act. Provides for Federal financial assistance for industrial projects, public facilities, urban renewal, and occupa.- tional retraining in designated areas of chronic unemployment and underemployment. The Secretary of Health, Education, and Welfare is responsible for providing assistance for occupational re- training of persons referred to him by the Secre- tary of Labor, through contracts with State vocational education agencies or with educational institutions. Manpower Development and Training Act of 1962. Authorizes the Secretary of Labor to determine the skill requirements of the economy, encour- age the development of programs, including on- the-job training, to equip the Nation's workers with the new and improved skills that are required; makes Secretary of Health, Education, and Welfare responsible for entering into agree- ments with States to provide occupational train- ing to unemployed or underemployed persons referred to him by the Secretary of Labor, ete. WELFARE AND INCOME MAINTENANCE Social Insurance and Protection Servicemen's and Veterans' Survivor Benefits Act (includes Public Health Service officers; also amends Title IT of the Social Security Act). Extends coverage under the OASDI program to 31 July 12, 1960 July 12, 1960 May 1, 1961 March 15, 1962 Aug. 1, 1956 86-613 86-618 87-27 87-415 84-881 Legislation Effecting Major Program Changes (cont.) Date Enacted Public Law members of the uniformed services on a contrib- utory basis. Social Security Amendments of 1958. Increase benefits under OASDI, improve actuarial status of the Trust Funds, and amend the public assistance and maternal and child health and welfare provisions of the Social Security Act. Public Assistance Public Welfare Amendments of 1961. Amend Title IV of the Social Security Act to authorize Federal financial participation in aid to dependent children of unemployed parents; also includes Federal payments for foster home care of dependent children, one-year extension of appropriation authorization for training grants for public welfare personnel, and increases maximum medical care expenditures (in behalf of old-age assistance recipients) with respect to which there will be Federal participation. Juvenile Delinquency Juvenile Delinquency and Youth Offenses Control Act of 1961. Provides for Federal assistance Tor projects which will demonstrate or develop techniques and practices leading to a solution of the Nation's juvenile delinguency control problems. Aug. 28, 1958 May 8, 1961 Sept. 22, 1961 85-840 87-31 87-27h Legislative Developments, 1961-1962 In both 1961 and 1962 President Kennedy sent to the Congress special messages on education and health. In addition the President transmitted special messages in 1962 on public welfare and consumer protection--these were subjects of Presidential messages for the first time. two years, Congress enacted and President Kennedy approved legislative improvements in health, education, and welfare. brought about needed improvements and changes in the basic During the past 26 significant These enactments programs of the Department. In addition, important new programs of Federal assistance to States and local governments were initiated which will be of great significance in the solution of health and social problems. 32 Legislation Enacted, 1961-1962 Public Law HEALTH Drug Amendments of 1962 87-781 Federal Water Pollution Control Act Amendments of 1961 87-88 National Institutes of Child Health and Human Development and of General Medical Sciences 87-838 Community Health Services and Facilities Act of 1961 87-395 Transfer of Freedmen's Hospital to Howard University 87-262 Health Clinics for Domestic Migratory Farm Workers 87-692 Air Pollution Control Act 87-761 Vaccination Assistance Act of 1962 87-868 EDUCATION AND TRAINING Manpower Development and Training Act of 1962 87-415 Practical Nurse Training Extension Act of 1961 87-22 Area Redevelopment Act - Vocational Retraining 87-27 Training of Teachers of the Deaf 87-276 Captioned Films for the Deaf 87-715 American Printing House for the Blind 87-294 Extension of NDEA and Impacted Area Program 87-34k4 Repeal of Disclaimer Affidavit in National Defense Education Act 87-835 Educational Television 8T7-LhT Surplus Property for Schools for the Physically Handicapped and Mentally Retarded, Educational Radio-TV, and Public Libraries 87-786 WELFARE AND INCOME MAINTENANCE Public Assistance Amendments of 1961 (Aid to Dependent Children of Unemployed Parents) 87-31 Public Welfare Amendments of 1962 87-543 Public Works Acceleration Act 87-658 Social Security Amendments of 1961 87-64 Assistance to U. S. Citizens Returned from Abroad 87-64 Juvenile Delinquency and Youth Offenses Control Act of 1961 87-274 Migration and Refugee Assistance Act (Cuban Refugee Program) 87-510 Alien Orphan Legislation 87-301 33 Federal Budget and Departmental Appropriations During the period under review, Federal budget expenditures increased from $74 billion in 1953 to $9U billion in 1963, and the Department of Health, Education, and Welfare's appropriations rose from $2 billion to $5 billion. The gross national product increased from $365 billion in 1953 to over $550 billion in 1963. The Department's appropriations amounted to .06 percent in 1953 and .09 percent in 1963--still less than one percent of the gross national product. A consistent aspect of the Department's expenditures has been that 90 percent of its funds are allocated in the form of grants to States, local communities, and institutions. Despite the increase in these programs, Department of Health, Education, and Welfare grants have actually declined as a percentage of total grants of the Federal government. Whereas the Department's grants amounted to 63 percent of total Federal grants in 1953, they had declined to Ul percent in 1963. This change is accounted for by increased Federal expenditures for highways and airport construction, housing and urban redevelopment, preservation of national resources, and promotion of agriculture. A comparison of the appropriations for the programs of the Department of Health, Education, and Welfare in fiscal year 1954 (its first full year) and in fiscal year 1963 reveals important changes in emphasis. As noted above, appropriations moved up from almost $2 billion in 1954 to over $5 billion in 1963. Grants to the States for public assistance increased sub- stantially in this period, reflecting such factors as the increase in the number of recipients of aid to dependent children and frequent Congressional enactment of amendments increasing the Federal share of welfare payments and adding new categories of recipients. These Federal payments to States for the needy and destitute account for the great bulk of appropriations to the Department, an amount which is governed by the magnitude of State action and State expenditures on these programs. Intra-mural Operations In contrast with the grant programs of the Department, the direct (intra-mural) activities have averaged about 10 percent of the Department's funds. The largest single activity in this category in recent years is direct research, mostly health research of the National Institutes of Health. Another large amount, almost one-quarter of intra-mural funds, finances patient care activities through the Indian health program, the Public Health Service hospital system, Saint Elizabeths Hospital for the mentally ill, and Freedmen's Hospital. Among other intra-mural activities, significant sums are used for regulatory programs such as that of the Food and Drug Administration, for civil defense activities, and for special foreign currency research programs. 34 Administration of the large grant programs of the Department took about six-tenths of one percent of the total funds of the Department, excluding trust funds. Staff As Congress has added new responsibilities, the staff of the Depart- ment has grown from about 37,000 in 1954 to approximately 82,000 in 1963. Of this total, 45 percent were engaged in administering the old-age, survivors, and disability programs (the cost of which is not borne from general revenue funds), 22 percent for patient care programs, and 19 percent for direct research and technical assistance to the States. The largest part of the staffing increase between 1954 and 1963 is accounted for by the social security (OASDI) program. Annual benefit pay- ments under this program will reach $15 billion in 1963. A portion of the OASI growth is attributable to the national increase-in workload deriving from population growth, and part to the frequent amendments to the Social Security Act which have been enacted by the Congress, giving social security coverage to more people, creating the disability benefit program, and modifying and liberalizing the existing benefits. A testimonial to the efficient operation of this program has been the remarkably small proportion of contribution income--25 percent--represented by administrative costs. Apart from the far flung organization of the Social Security Admin- istration, the next largest single group of employees in the Department are those engaged in the direct care of patients in the Public Health Service Hospitals, which provide care for merchant seamen, American Indians, and other Federal beneficiaries, and in Saint Elizabeths and Freedmen's Hospitals in the District of Columbia. The expansion of staff in these programs is related to the expansion of coverage and the improvement of the quality of this care. A third large block of employees are those carrying out direct medical research and the administration of research grant programs on the National Institutes of Health campus at Bethesda. The increase of about 7,000 employees over the period is primarily a measure of the extraordinary emphasis placed by the Congress on this field of endeavor in the past ten years. Increases of lesser magnitude, but still very significant, have been experienced in most other departmental programs, particularly those con- cerned with research and technical assistance to States and local communities in the fields of community and environmental health, and the consumer pro- tection programs of the Food and Drug Administration. 35 Towards the Future At the close of the Department of Health, Education, and Welfare's first decade certain signposts pointing to the activities of the Department ‘during the following decade had become visible. The change of emphasis from amelioration to prevention and development was fortified by increased emphasis within the Office of the Secretary upon program interests which are found in more than one agency of the Department, as a result of the related responsibilities of the agencies. Major attention has been devoted to strengthened programs in the field of aging, juvenile delinquency, mental retardation, consumer protection, manpower development and training, and educational television. In recent years the international responsibilities of the Department had expanded considerably along with an increasing reali- zation around the world that social reforms are major factors in national growth and stability. At the very end of its first ten years the Department undertook its most important organizational change by creating a new Welfare Administra- tion, separating the Children's Bureau and the Bureau of Family Services from the Social Security Administration in order to give added prominence to these major programs. Proposals for Federal action to further improve the Nation's health, education, and welfare have been made by President Kennedy this year in five special messages dealing with education, health, mental health and mental retardation, youth, and aging. The last three topics were the subjects of a special Presidential message for the first time in history. These messages indicate the areas in which improvements in existing programs are desirable and necessary. Departmental Organization and Agency Developments, 1953-1963 The Departmental developments during the past ten years, as described above, have added a considerable number of new responsibilities to the pro- grams of each agency of the Department. In response to these added responsi- bilities, a number of organizational changes were necessary. On the following pages, organizational charts showing the structure of the Department in 1953 and in 1963 are reproduced. Following the charts, a brief account of each agency's developments during the decade is presented. A final page reviews developments in the three educational institutions (Gallaudet College, Howard University, and the American Printing Ilouse for the Blind) which are supported by the Department. 36 DEPARTMENT OF HEALTH. EDUCATION, AND WELFARE : 1953 Under SPECIAL ASSISTANT FOR HEALTH AND MEDICAL AFFAIRS Assistants to the Secretary SECRETARY Secretary posed SECRETARIAT TO DEPARTMENTAL COUNCIL OFF ICE OF INTERNAL SECURITY OFF ICE OF PUBLICA- TIONS AND REPORTS ASSISTANT SECRETARY for PROGRAM ANALYSIS OFF ICE OF LEGISLATIVE LIAISON X COMMITTEE ON AGING AND GERIATRICS OFFICE OF THE GENERAL COUNSEL OFFICE ADMINISTRATION ASSISTANT SECRETARY FEDERAL-STATE RELATIONS for OF OFFICE OF DEFENSE SPECIAL ASSISTANT | | | | | | | | | | | | | | | | | | | | I | | | | | | te PUBLIC HEALTH SERVICE ON FEDERAL -STATE COORD INATOR PeOBLEMNS PROGRAM ANALYSIS ASSISTANT FORLL | ASSISTANT FOR Jd | Cem DIVISION OF ADMIN ISTRAT|O LEGISLATION BUDGET & FIN.[f | ADM. PLANNING OFFICE OF PIED CIAYSON WINE SERVICES SPECIAL INSTITUTIONS DIVISION OF DIVISION OF DIV. SERVICE PUBLIC HEALTHI | | WELF. & EDUC. OPERATIONS SURPLUS GRANT-IN-AID AM.PR HOUSE COLUMB. INST. PROPERTY AUDITS FOR BLIND FOR DEAF DIVISION OF DIV. OLD-AGE DIV. LIBRARY FOOD & DRUGS & SURV. INS. SERV ICES STATE MERIT HOWARD SYSTEMS UNIVERSITY SOCIAL SECURITY FOOD AND DRUG OFFICE OF YOCATIONAL SAINT ELIZABETHS OFFICE OF EDUCATION ADMINISTRATION ADMINISTRATION REHABILITATION HOSPITAL DIV.STATE & DIV. BUSINESS DIVISION OF DIVISION OF DIV. MEDICAL DIV. MEDICAL DIVISION OF LOC.SCH. SYS. OPERAT | ONS REGULA.MGT. ADMINISTRA. SERVICES SERVICES ADMINISTRA. OFF ICE OF THE SURGEON GENERAL BUREAU OF STATE SERVICES NATIONAL INSTI - TUTES OF HEALTH BUREAU OF MEDICAL SERVICES December 1953 DIV. VOCA. DUCAT [ON DIV.SCH.ASST. FED- AFF . AREAS BUREAU OF OLD-AGE & SURV. INSURANCE BUREAU OF PUBLIC ASS I STANCE CHILDREN'S BUREAU BUREAU OF FEDERAL CREDIT UNIONS D1V.PROGRAM | 2 STATE RESEARCH COOPERATION DIV.PROGRAM DIV. RESEARCH SERVICES & STATISTICS DIVISION MEDICINE = 3 DIVISION OF MICROBIOLOGY DIVISION OF FOOD DIVISION OF PHARMACOLOGY L DIV. FIELD OPERAT | ONS [mt see ems sm me et ee et ee ee et ORGANIZATIONS SERVICES FOR THE BLIND D.C. REHAB. SERVICE DIV.ST.PLANS AND GRANTS Secretfyfy DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE : 1963 SECRETARY ASSISTANT TO THE SECRETARY Under Secretary ASSISTANT TO THE SECRETARY (PUBLIC AFFAIRS). — _ _ _ _ _ ASSISTANT TO THE UNDER SECRETARY OFFICE OF SPECIAL ASSISTANT TO THE SECRETARY (Health and Medical Affairs) SECRETARY DIRECTOR OF PUBLIC INFORMATION ADMINISTRATIVE ASSISTANT ASSISTANT SECRETARY 1 | DIRECTOR OF SECRETARY ASSISTANT SECRETARY GENERAL COUNSEL FIELD ADMINISTRATION OOKKRX KKK XXX XXX XXX AY 3 FEDERALLY AMERICAN PRINTING GALLAUDET HOWARD AIDED COR- I PORAT IONS HOUSE FOR BLIND COLLEGE UNIVERSITY VOCATIONAL REHABILITATION FOOD AND DRUG SOCIAL SECURITY PUBLIC HEALTH SERVICE OFFICE OF EDUCATION ADMINISTRATION 2] SAINT ELIZABETHS HOSPPTAL ADMINISTRATION ADMINISTRATION WELFARE ADMINISTRATION OPERATING Office of the Surgeon General Office of the Commissioner Office of the Commissioner 5 Office of the Superintendent Office of the Commissioner Office of the Commissioner Office of the Commissioner AGENCIES National Center for Health Division of Research Statistics % Bureau of Educational Office of Assistant Commissioner, PY Division of Administration Bureau of Enforcoment and Statistics Office of Aging ) } Research & Development Management Services Division of Program Bena of Medical Services . ) ] SET Division of Medical Services Bureau of Medicine Evaluation and Planning Office of Juvenile Delinquency reedmen’s Hospital Bureau of International Office of Assistant Commissioner, Division, of the Actuary ond Youth Development Education Research and Training ibd Bureau of State Services Bureau of Biological and Office of Information Bureau of Educational Office of Assistant Commissioner, Physical Sciences Central Planning Staff Cuban Refugee Program Staff National Institutes of Health Assistance Programs State Program Operations Di of Claims Policy Bureau of Field Division of Management Bureau of Family Services National Library of Medicine Office of Assistant Commissioner, Administration Division of Field Operations Health & Medical Act Division of Accounting Operations Children’s Bureau Bureau of Program Planning Division of Claims Control and Appraisal Division of Disability Operations 4 ~ Bureau of Hearings and Appeals Bureau of Federal Credit Unions SOCIAL SECURITY ADMINISTRATION MAJOR PHS FIELD INSTALLATIONS DEPARTMENT REGIONAL OFFICES HOSPITALS QUARANTINE STATIONS REPRESENTING OUTPATIENT CLINICS SHELLFISH SANITATION INDIAN AND ALASKA RESEARCH CENTERS THE SECRETARY NATIVE ROseIIALS RIVER BASIN PROJECT F INDIAN AND Al OFFICES GEHERAL COINS SI: FOOD AND DRUG a ; ELD NATIVE HEALTH CENTERS RADIOLOGICAL HEALTH DIRECTOR OF FIELD ADMINISTRATION District Offices + INDIAN AND ALASKA LABORATORIES ORGAN - NATIVE FIELD OFFICES NIH FOREIGN RESEARCH PUBLIC HEALY SERVICE INDIAN AND ALASK; OFFICES SOCIAL SECURITY ADMINISTRATION Payment Centers ZATIONS NATIVE AREA OFFICES ROL tee ation ro — ARCTIC HEALTH RESEARCH CENTER VOCATIONAL REHABILITATION Hearing Examiner Offices COMMUNICABLE DISEASE CENTER MIDDLE AMERICA RESEARCH UNIT OCCUPATIONAL HEALTH RESEARCH AND TRAINING FACILITY ROCKY MOUNTAIN LABORATORY SANITARY ENGINEERING CENTER ADMINISTRATION WELFARE ADMINISTRATION March 5, 1963 THE PUBLIC HEALTH SERVICE, 1953-1963 Over the past decade the Public Health Service broadened its support of research studies, training of research personnel, and construction of research facilities by private, nonprofit institutions. The scope of research conducted has undergone similar expansion: a 500-bed Clinical Center was opened at the National Institutes of Health in 1953; the seventh institute in the NIH complex--the Institute of Allergy and Infectious Diseases--was established in 1957; and in 1962 Congress approved the creation of Institutes of General Medical Sciences and of Child Health and Human Development. Highlights of research by PHS scientists and grantees include advances in cancer chemotherapy and in open heart surgery, development of vaccines against influenza and upper respiratory infections, improved drugs for arthritics and mental patients, and the partial "cracking" of the genetic code. Emphasis has been placed on training grants, fellowships, and traineeships to help increase the Nation's supply of doctors, nurses, and other specialized medical and health personnel. Over $1 billion has been spent since 1953 under the Hill-Burton program for the construction of hospitals, nursing homes, and other health facilities. A major national effort against environmental health hazards has gained momentum, resulting in the establishment of a number of new Public Health Service divisions and field laboratories. Legislation since 1953 has provided authority for expanded programs to study and control air and water pollution. In 1958 responsibility for the collection, collation, and dissemination of data on environmental radioactivity was delegated to the Service by the Secre- tary of DHEW. Radiological health activities were intensified following the resumption of atmospheric nuclear testing in 1961. Continued progress has been made in combatting occupational health hazards and general sanitation problems, including food-borne diseases. The critical need for comprehensive health services led to passage of the Community Health Services and Facilities Act of 1961 which authorizes PHS grants for community studies and demonstrations to develop new or improved out-of-hospital services, particularly for the aged and chronically ill. The health standards of American Indians and Alaskan Natives have been steadily improved through a broad program of preventive and curative medical services since responsibility for health care was transferred from the Department of the Interior to the Public Health Service in 1955. A National Library of Medicine was established in 1956; work began in 1961 on an electronic data processing system known as MEDLARS to improve the capacity to store, retrieve and disseminate information. Major PHS components engaged in measuring the Nation's health status were brought together in 1960 in a National Center for Health Statistics. 39 SATNT ELIZABETHS HOSPITAL, 1953-1963 The retirement in October 1962 of Dr. Winfred Overholser, long Super- intendent of Saint Elizabeths, provided an occasion for assessing the many changes that have taken place at the Hospital: Patient Movement. There was a reversal of the long-term climb in the number of patients in the Hospital but turnover and general patient activity increased. From a peak of 7,278 patients in June 1955, the average patient census declined at an accelerating rate to 6,771 in June 1962. The number of patients on visit or leave statuses rose from about 250 to over 1,100. Almissions increased by 41 percent from 1,438, ten years ago, to 2,024 in 1962; discharges doubled from 814 to 1,649. Voluntary admissions increased two and one-half times. Changes in Staff and Facilities. The staff grew from 2,500 employees to 3,700, and the number of physicians increased from 43 to 82, but staff shortages are still acute. Since 1956 several new buildings have been opened including one for the admission and treatment of patients under age 6k, an inter-faith chapel, a maximum security building, and a physical rehabil- itation building. Older buildings, equipment, and furnishings are being refurbished, and appropriations have been made for a psychiatric-rehabilita- tion center. Changes in Treatment Methods and Programs. The use of tranquilizing drugs Was shown to be effective; psychosurgery (lobotomy) was discontinued. Racial integration was achieved without notable incident. The development of the "therapeutic community" was begun; studies of the inter-relationships of staff, personnel and patients, and partial self-government by patients was initiated. A successful re-employment program for rehabilitated patients was developed. Publication of the report of the Joint Commission on lental Health stressed new concepts of patient care, and a vigorous attempt was nade, with increasing success, to send patients out to nommedical facilities. Developments of National Significance. The Durham Decision of 1954 initiated constructive changes in attitudes toward criminal responsibility of the mentally ill. The Hospital Centennial was observed in 1955 with a two-day scientific program featuring papers read by U. S. and foreign psychiatrists and subsequently published in book form. The Clinical Neuropharmacology Research Center (1957), and the Behavioral and Clinical Studies Center (1961) were established in collaboration with the National Institute of Mental Health. A 1960 statute made certain U. S. nationals who become mentally ill while abroad eligible for admission to the Hospital. In 1962 an effort toward educating the general public regarding mental illness was made in a series of 26 five-minute transcribed broadcasts, heard in every State over some 450 radio stations. THE FOOD AND DRUG ADMINISTRATION, 1953-1963 For the Food and Drug Administration, the past decade has been one of steadily increasing responsibility and correspondingly rapid growth. Scien- tific progress, new legislation, and a new public awareness of the importance of consumer protection contributed to the evolving pattern. Much of the change was stimulated by new product development in the regulated industries. Miraculous new chemicals for agriculture, strange new additives for processed foods, life-saving but potentially dangerous new drugs, and useful but hazardous household chemical aids demanded stronger controls to keep public benefits and public risks in balance. Marking a new trend in consumer protection, the principle of premar- keting safety clearance by the Government, pioneered for new drugs and color additives in 1938, was extended to pesticides in 1954 and to additives for processed foods in 1958, and was further strengthened for color additives in 1960. In each case safety controls were provided to limit the amounts of new chemicals allowed in consumer products. These controls aim for prevention of harm rather than after-the-fact punishment or correction of violations. The burden of proof of safety is on the manufacturer. The Hazardous Substances Labeling Act of 1960 contains labeling require- ments aimed at protecting children and others from accidental injury from the many hazardous chemicals in use and storage in every household. The Kefauver-Harris Drug Amendments of 1962 represent another milestone in consumer protection legislation. This new law extends the premarketing clearance principle to require that new drugs be proved both safe and effec- tive before they are marketed, and provides other new controls to assure the integrity of drugs. To keep pace with scientific and legislative developments, FDA has increased its scientific staff and broadened its scientific competence to assure proper evaluation of the safety of products for their intended use. Through application of the most modern methods and equipment, FDA has becone one of the world's leading laboratory institutions in the analysis of foods, drugs, and evaluating the safety of additives. The mid-1950's had found the Food and Drug Administration at a low point in its ability to discharge its responsibilities. Despite rapidly multiplying problems in consumer protection, there were fewer enforcement personnel in 1955 than in 1941. Actions against frauds and cheats had to be stopped in order to carry out programs directly related to the public health. A Citizens Advisory Committee appointed by the Secretary in 1955 to study FDA's responsibilities and resources pointed up the need for additions to staff, better facilities, and better equipment. The Committee report managed to communicate FDA's needs, and marked a turning point that presaged an era of growth and development. Appropriations increased from $5.6 million in 1953 to $28.3 million in 1963; budgeted positions rose from 829 in 1955 to 3,012 in 1963. A new headquarters building in Washington is nearing completion, and new and improved laboratories have been provided for 11 of the 18 district offices. ba THE OFFICE OF EDUCATION, 1953-1963 Since becoming a part of the Department of Health, Education, and Welfare on April 11, 1953 (P.L. 83-13), the Office of Education has passed through the most significant period in its 96-year history as the primary education agency of the Federal Government. The original mandate of the Office for gathering statistics and facts has been strengthened by legisla- tive enactments. The Office identifies needs, evaluates resources, and provides professional and financial assistance to strengthen areas of educa- tion where there is an urgent national interest. Financial aid for research, experimentation, and demonstration to extend basic knowledge in education was made possible through legislation in 1954 (P.L. 83-531). The Cooperative Research Program enables projects to be supported in such fields as: retention of students, special abilities, mental retardation, staffing of schools and colleges, school and college organization and administration, instructional subjects of special concern, such as mathematics, sciences, and modern foreign languages, and the teaching of English. The Office disseminates information and seeks ways to translate into theory and ultimately into practice in education the findings of the research completed. Other significant programs that have been added by new legislation during the past ten years include: A grant-in-aid program to assist States in extending public library services to rural areas was provided by the Library Services Act of 1956 (P.L. 84-597, as amended). The most signifi- cant financial assistance for education which was added during the ten-year period was the National Defense Education Act of 1958 (P.L. 85-36, as amended). It authorized more than $1 billion in Federal aid from elementary through graduate school with student loans being the largest single item in the program. Federal assistance for the retraining of unemployed or underemployed persons has been provided by the Area Redevelopment Act of 1961 (P.L. 87-415). A ten-year program of $1 million a year in grants to institutions of higher learning and to State educational agencies to encourage expansion of education in the teaching of the mentally retarded was authorized by the Education for the Mentally Retarded Act of 19538 (P.L. 85-926, as amended). Grants to educational institutions that are training teachers of the deaf, and for scholarships, are provided by the Training Teachers for the Deaf Act of 1961 (P.L. 87-276). The Office has continued during the past decade to collect, analyze, and publish national statistics on education at all levels. h2 THE SOCIAL SECURITY ADMINISTRATION, 1953-1963 The social security programs were significantly improved and expanded during the decade since the establishment of the Department of Health, Educa- tion, and Welfare. Disability benefits were added to the old-age and survivors insurance program and the coverage of the system was extended to almost the entire working population. There were two general increases in benefit amounts, an additional increase in the minimum payable, and an upward adjust- ment for aged widows. Other liberalizations in the law included lowering the retirement age from 65 to 62, raising the amount that a worker can earn witho out losing benefits, and omitting up to 5 years of lowest earnings in calcu- lating benefits. The number of beneficiaries more than tripled during the decade. The Federal financial share in the public assistance programs was increased over the ten-year period, and provision was made Tor proportion- ately more help to those States where need is greatest and income and financial ability least. States were encouraged to extend and improve the medical care available to public assistance recipients, and a special program was started for elderly persons who are medically indigent. Increasingly over the decade, the public assistance programs assumed the role originally intended for them, i.e., as supplementary to the basic social insurance program. With social insurance providing more and more effectively for minimum economic security, an increasing proportion of those on public assistance rolls were families with multiple problems and disad- vantages. Provisions for social services by trained public welfare staff to such families and potentially dependent families were made in amendments to the Social Security Act. Child welfare services were also expanded to better serve the current needs of the Nation. In this program and the maternal and child health and crippled children's programs, increased Federal financial support and leader- ship served to stimulate State and local action. Intramural research in social security was expanded, moving toward the exploration of fundamental questions in the area of human resources and social welfare. Extramural research programs were initiated to acquire needed know- ledge about causes and prevention of dependency, improvement of child welfare and reduction of delinquency. Federal credit unions more than doubled their membership and tripled their assets to enhance their worth as a valuable adjunct to the social security programs. From 1958 on, the Bureau of Federal Credit Unions was supported entirely from fees for chartering and supervising local credit unions. Responsibility for the Department's social security programs was realigned effective January 28, 1963. The Social Security Administration was made responsible for the programs of the Bureau of 0ld-Age and Survivors Insurance, the Bureau of Hearings and Appeals, and the Bureau of Federal Credit Unions; and a Welfare Administration was organized with responsibility for the programs of the Bureau of Family Services and the Children's Bureau, the work of the special staffs on aging and juvenile delinquency, and the Cuban refugee program. k3 THE VOCATIONAL REHABILITATION ADMINISTRATION, 1953-1963 Jajor progress has been made in rehabilitation of handicapped persons to productive and satisfying life. A new charter of operations passed in 1954 (P.L. 83-565) provided for expansion of the program of vocational rehabilitation through four major devices: 1. Adoption of a new grant-in-aid system to increase Federal and State funds for expanding services to disabled people. Rehabilitations rose from 55,800 in 1954 to 102,400 in 1962. Funds increased from $36 million ($23 million Federal and $13 million State) in 1954 to $173.4 million for 1963 ($100.4 million Federal, $73 million State). 2. Authorization of major programs of Research and Training. About 600 research and demonstration projects have been approved in many areas including mental retardation, mental illness, blindness, speech and hearing problems. Research funds of $146.2 million have been committed. Teaching and training grants totaling $47 million have enabled about 6,000 students to obtain training in short-supply professional fields. 3. Temporary authority and support of incentive grants to expand services and facilities brought establishment or improvement of 112 facili- ties and workshops at a cost of $2.7 million in Federal and matching funds. 4. A continuing program of incentive extension and improvement grants, combined with regular support grants, have resulted in establishment or improvement of 280 facilities and workshops at a cost of $14.4 million in Federal and State funds. In 1954, the Congress also authorized Federal money for constructing community rehabilitation facilities under the Hill-Burton program. This has resulted in 23k facilities of various types from $43 million of Federal funds and $102 million of local money. In the same year the Social Security Act was amended to protect the retirement rights of disabled workers under OASI, and subsequent amendments made cash benefits payable to disabled workers, first over age 50, and then for such workers and dependents regardless of age. In these amendments Congress brought the concept of vocational rehabilitation into integral relationship with disability protection and expressed a preference for State vocational rehabilitation agencies to make disability determinations of persons applying for disability benefits, simultaneously affording them an opportunity for vocational rehabilitation services. The Vocational Rehabilitation Administration is encouraging State voca- tional rehabilitation agencies to conduct with public assistance agencies cooperative demonstrations of rehabilitation of public welfare clients. Four such projects are underway or in advanced planning stages in California, Oregon, Vermont and New Jersey; many more are expected within the year. The recent elevation in status from Office to Administration, coincident with creation of the Welfare Administration, underlines the importance of rehabilitation of dependents through cooperative effort. FEDERALLY -ATDED EDUCATIONAL INSTITUTIONS, 1953-1963 Gallaudet College, the only college for the deaf in the world, was founded in 136k to provide a liberal higher education for deaf persons who need special facilities to compensate for their loss of hearing. Gallaudet College's most significant development in the past ten years has been accreditation by the Middle States Association of Colleges and Secondary Schools. The completion of 8 new buildings during the past decade have enabled Gallaudet to accommodate an increased enrollment which now numbers 600 and includes students from all over the world. A milestone in the education of the deaf has been achieved with the admission of deaf students into the graduate program for training teachers of the deaf. Gallaudet College is one of the 40 colleges participating in the Program for Training Teachers of the Deaf under Public Law 87-276. The most significant events which have occurred at Howard University in the past ten years include the establishment of programs leading toward the Doctor of Philosophy degree, begun in 1955 in the Department of Chemistry and expanded to the point where Ph.D. degrees are now offered in seven fields of study; the construction of nine new buildings, which have enabled the University to keep its physical plant abreast of academic expansions; the introduction of an academic program in African Studies; the election of Dr. James Madison Nabrit, Jr. as President of Howard University in July 1960. In addition, during the past ten years foreign student enrollment has grown to the point where Howard University now has the largest percentage of foreign students of any American university, approximately 16 percent of the total student body. Since 1953 national honor societies have been added in many areas of study, including the most renowned, Phi Beta Kappa and Sigma Xi. The American Printing House for the Blind, which is the largest publishing house and manufacturer of special devices for the aid of the blind in the world, is the official channel through which the United States Government serves the States and the blind children in them. Allot- ments of credit are made to the schools for the blind and to the State departments of education against which they send in orders for materials manufactured at the American Printing House for the Blind based upon the number of children registered with this establishment by each State. This act has been amended several times, most recently in 1961 by Public Law 87-294, and is reviewed periodically to determine the adequacy of its provisions in light of changing developments in the field. The growing magnitude and com- Plexity of the unmet needs in this area have been cause for increasing concern. Public Law 87-294 removes the limitation on the amount of appropriation and the provision for representation of State educational agencies on the board of trustees of the American Printing House for the Blind. In 1879 about 2,200 pupils were being educated in our schools for the blind and the Federal appropriation to the Printing House that year amounted to $10,000. In 1952 a total of 6,145 pupils were served under & Federal Quota of $125,000. In 1962, 15,973 pupils were served under a Federal Quota of $639,000. An additional $41,000 were provided that year so that the Printing House could render advisory services to the States. 5 COMMUNITY NEEDS AND GOALS FOR COMMUNITY SERVICES Irvin Walker and Eugenia Sullivan This Nation has long been committed to the principle that each individual should have the opportunity to realize his full potential for productive living. To achieve this goal, the community must not only remove obstacles to personal development, but must also provide positive stimulus by making available to its citizens a wide range of coordinated community services. In an era of unprecedented social and technical changes, the central challenge is to make certain that institutional arrangements in our society sensitively reflect the needs of individuals, families, and communities. The nature of the challenge that will face us in the decades ahead is fairly well indicated by social and economic trends which are clearly identifiable today. Industrialization, urbanization, the development of suburban communi - ties, technological changes and automation, and a highly mobile population have been associated with increased economic productivity, lengthening of life, shifts in the size and structure of the family and the increased par- ticipation of women in economic and community activities, Each of these changes, however fortuitous, has raised new problems in economic behavior, social organization, and human relations. The trend toward urban-suburban living has given rise to an increased isoletion of individuals and families and has focused fresh concern on the need to strengthen neighborhood and community bonds. The complexity of urban life in a highly fluid society has increased the urgency of identifying gaps in the institutional structure and of providing instruments for making serv- ices available to people who need them. COMMUNITIES: DYNAMICS AND PROBLEMS Population Growth Planning to meet the health, welfare, educational, and related needs of the future must first of all take account of the expected growth of the population in the decades ahead. The population of the United States is in- creasing rapidly--currently at the rate of about 3 million a year--or the addition of a city nearly the size of Chicago each year. By 1980 the popu- lation will reach about 250 million, according to the latest Census Bureau projections. Mr. Walker is a Program Analysis Officer and Miss Sullivan is a Staff Assist- ant in the Office of the Assistant Secretary (for Legislation). Excerpt from "Goals for Commmity Services" (February 28, 1963; 29 pages) prepared in the Office of the Assistant Secretary for Legislation, Department of Health, Education, and Welfare. Health, Education, and Welfare Indicators, May 1963 Revised U6 Within this over-all growth, there is a striking shift in the proportion of people at both ends of the life span. The continuing increase in the school-age population, combined with a rising level of educational expectation, will necessitate greater investment in educational facilities and related services such as junior colleges, community libraries, school health services, and recreational centers. By 1980 some 25 million people--ten percent of our population--will be aged 65 and over. Over the past decade, the most striking increase has been in the age group 75 and over, where the problems of old age become par- ticularly acute. The rapid growth of the older population is a relatively new experience for many communities as well as for the nation. Most communities are just now in the process of organizing services to meet the basic needs of older people; they are searching for precedents in other communities to guide them in the development of facilities and serve ices; and there are few trained persons with a knowledge of aging capable of providing guidance to them. The Implications of Urbanization Moreover, the United States is rapidly becoming a nation of urban- suburban dwellers. About two-thirds of the American people live in metro- politan areas; by 1980, it is likely that 80 percent of the population will live in urban areas. Clearly visible trends show that there will be a con- tinuing out-migration both from rural areas and from the big central cities, with the suburban areas registering large population gains. The flight of middle-class families to suburban areas will leave increasingly large con- centrations of marginal and dependent individuals and families in the central cities. As a result of population shifts, the social, economic and ethnic character of city populations is undergoing profound changes. Persons from impoverished rural areas are migrating to the large cities. At the same time the flight to the suburbs of the middle-class continues, particularly among families with young children seeking what they consider adequate liv- ing conditions and school facilities. The proportion of older people is higher in the central cities; an age distribution from the 1960 Census of residents of the 10 largest metropolitan areas (which contain about a fourth of the United States population) shows that 10.5 percent of the central city population is 65 or over while only 7.5 percent of the suburban population is in this older age group. Many new in-migrants to the central cities are not equipped to cope with urban living. Many are unskilled; many are functionally illiterate. Lacking the most rudimentary tools of reading, writing, and mathematical skills, they are unable to fill out a job application, read work instruc- tions, and in some cases cannot even read street and bus signs. Unless basic literacy education and job training are provided these people, they will remain permanently unemployed. Moreover, lack of skills and illiter=- acy are not confined to new arrivals in the cities; many long-time residents are among the marginal and dependent populations. h7 The loosening of family and neighborhood ties in urban areas has aggravated and increased social maladjustment. Juvenile delinquency, for example, is a serious problem in every large city in the United States. Over two-thirds of all delinquency court cases are handled in urban courts. The extent of delinquency among youth is greater than court case figures would indicate, since many instances of what may be termed delinquent be- havior are dealt with outside the courts or may go undetected or unappre- hended. Thus, the central cities face rising pressures for services stemming from the fact that they have an increasing proportion of older people and the unskilled at a time when out-migration to the suburbs of both the well- to-do and industry drains their tax resources and decreases their ability to provide community services. On the other hand, suburban areas in many instances are neither large enough nor sufficiently well organized and financed to meet the needs of their growing populations. Resources are strained as new streets, sewers, utilities, telephone lines, schools, libraries, community centers, churches, playgrounds, and the like must be built for the use of the growing population. At the same time, the central cities must continue to maintain services and facilities at the same, or indeed higher, cost while many of them are actually losing population--between 1950 and 1960 eight out of the ten largest cities in the United States lost population. “hese changes have major implications for persons concerned with planning for current and emerging human needs. Relations between levels and units of government and concepts of civic responsibility clearly need re- appraisal and reshaping as more and more people work and have general daily contacts in a city, yet vote and pay taxes in suburban areas outside of the city. Economic Change Major public policy determinations are based on the prospects of and necessity for economic growth, with increased employment, expanded output, and higher standards of living. At the same time automation will continue to render obsolete many unskilled and semi-skilled jobs, and even some skilled jobs and occupations, creating unemployment and problems of dependency. This in turn points to the need for changing patterns of vocational education to train the nation's youth to perform useful work in our increasingly complex technology and to retrain those in the working force whose skills are unde=- veloped or have become obsolete. According to the Department of Labor projections, in the next two decades there may be distinct imbalance in the labor force--a relatively constant percentage of workers in the 25 to 45 age group and a spectacular increase of older people and very young people. Indeed, workers under 25 are likely to account for nearly 50 percent of the labor force growth in the next 10 years. Certain groups of persons are particularly vulnerable to long-term unemployment of a structural nature. Technological change presents special 43 problems for older workers when the skill that has been the basis for their entire work experience becomes obsolete in their present place of employ=- ment. Older persons are less mobile, also, because of such factors as family and community ties and home ownership. The problem of structural adaptation of our manpower supply is not only one of readapting present members of the labor force to new jobs. The importance of appropriate education and training of new entrants into the labor force is apparent in the light of the fact that nearly one-third of all workers in our labor force in 1970 will have entered it during the 1960's. Altered Patterns of Family and Community Iiving The increase in the dependent population at both ends of the life span has placed new burdens on the family and has provided compelling need to effect a more equitable distribution of the costs of child rearing and old age. The typical family of the metropolitan area is made up of parents and their children. The large extended family of the past, which included grand- parents, unmarried aunts, and others living in the same household, is dis- appearing. The result is that many services that family members formerly per- formed, such as child care and nursing services for the chronically ill, must now be sought outside the family. Moreover, families and individuals are be- coming more and more mobile, with the result that people feel less identifi- cation with neighborhood and community institutions. Data from the Census Bureau show that one-half of all households moved at least once in the period 1955-59. Increasing participation of married women, and particularly mothers, in the labor force may be expected to continue. In 1961 over one-fourth of the labor force was made up of married women (including widowed and divorced) and 8.7 million of these women, or 12 percent of the labor force, were mothers with children under age 18. These mothers represent about one-third of all mothers of children under age 18. Some 3.2 million of these working mothers have children under age 6. These trends point to the increasing need to provide substitute care for the children of working mothers. Children from broken homes represent another problem of modern living. In 1959 of the 26.5 million families with children under age 18, 2.8 million (about 11 percent) were homes broken by death, divorce, or desertion. An in- creasing proportion of children receiving assistance under the aid to fami- lies with dependent children program are in families with the father "absent'e=- separated, estranged, divorced, or never married to the mother, The proportion of children born out of wedlock has tripled in 20 years to a level of more than one in 20. Two out of five mothers of babies born out of wedlock are under 20 years of age; about 2 percent are under 15 years. While it is impossible to know precisely all the causes contributing to ille=- gitimacy, studies show that certain environmental, socio-economic and psycho- logical problems are often associated with it. Faulty parent-child relation- ships, instability of parents and a harmful social environment, crowded living conditions, inadequacy of food and clothing, lack of supervised recreational facilities, racial hostility, and segregation are all factors provocative of illegitimacy. Lo The plight of families with small and inadequate incomes stands out in contrast to the general prosperity enjoyed during the last decade. In 1960 some 22 percent of the families in the United States, with annual in- comes of less than $3,000 per family, contained more than 13 million children. Many of the families were of the types that have median incomes below the average--the family headed by a woman ($2,968), the farm family ($2,875),and the nonwhite family ($3,233). Health Problems The considerable investment in medical research begun in the last decade will pay steadily increasing dividends of new medical knowledge. The time lag between the discovery and application of health knowledge is re=- ceiving increasing attention. It is resonable to assume that, as the 1940's and 1950's were the decades of growth and emphasis in medical research, the 1960's and 1970's will see greater application of health knowledge. These trends have been identified and described in various studies. However, perhaps the most significant concept for the future is just emerging. This is the proposition that comprehensive health services should be available where and when people need them. The continued growth of population means an increased workload on already overburdened and overextended community health services. The in=- crease in the younger and older age groups implies intensified demands since these two age groups are the heaviest per capita users of health services; and it also suggests an intensified economic burden, since the number of de- pendents per taxpayer will nearly double in the years ehead. Among the special health problems inherent in the trends for the future are the following: 1. Infant Mortality Although the infant mortality rate dropped in 1961 to the lowest ever attained for the United States (25.3 per 1,000 births), it was higher than that of 10 other countries. The infant mortality rate in the United States is more than three-fifths higher than that of Sweden and the Nether- lands. The disadvantaged groups in the United States, in particular the nonwhite, continue to have high infant mortality rates. The nonwhite in- fant mortality rate in large cities in 1960 was 43.2 per 1,000 live births as compared to 22,9 for whites. Infant mortality among reservation Indians in 1960 was estimated to be 46 per 1,000 births, nearly twice that of the general population. 2. The Chronic Diseases Prominent among the resulting consequence of the aging population is the increased importance of the chronic diseases. Fifty years ago, 30 deaths in every 100 were attributable to chronic diseases; today, these deaths total 66 out of every 100. In addition, chronic diseases account for about 60 out of every 100 disabilities. The problem will grow as the aged population continues to grow. 50 Today's health care needs, especially in the case of long-term illnesses and disabilities, require, in addition to the private physician who is directly concerned with the care of individual patients, the support of a combination Of institutions, including health departments, hospitals, chronic care facilities, nursing homes, clinics, diagnostic and rehabili- tation facilities; and such specialized personnel as visiting nurses, physical and occupational therapists, nutritionists, social workers, etc. The challenge to health authorities lies in the development, coordination, and improvement of these community techniques, methods, and organizations which comprise a comprehensive health care program. A major related goal is that the physically disabled should have the opportunity for restoration even though correction of the disability may not return the person to economic productivity. 3. Mental Health Nowhere in the health field is the need for rational planning and development of community services more evident than in the area of mental health. The past institutional arrangements for the care and treatment of the mentally ill often increased alienation of the emotionally ill by isolat=- ing them from the community and from their families. The relative magnitude of the mental health problem of our nation has been fairly well delineated. It is estimated that mental illness effects 17 million Americans, fills every other hospital bed, and costs over $3 billion annually. The role of community services in the mental health field is the subject of a major recommendation of the landmark report of the Joint Commission on Mental Illness and Health. The Commission recommends the development of State or regional systems of community mental health centers in communities of 50,000 as a "main line of defense in reducing the need of many persons with major mental illness for prolonged or repeated hospitali- zation." There is increasing agreement among authorities that huge isolated asylums are undesirable compared with facilities integrated into the frame- work of community health services. 4k. Mental Retardation In 1960 there were an estimated 5.4 million children and adults who were mentally retarded. Unless there are major advances in methods of prevention, there will be as many as one million more mentally retarded per- sons by 1970. This increase is predicated on anticipated general population growth, increased life span, and increased infant survival rates. Although mental retardation results from a complex of causes=-=- many of which are incompletely understood--we nevertheless know that certain community conditions produce excessively high rates of mental retardation. These conditions include low economic status, inadequate maternal and child care, unsatisfactory stimulation in the home and neighborhood environments, and a lack of provision for the education of children with special needs and problems. Community services for the mentally retarded must be related broadly and specifically to these conditions that spawn retardation. They 51 must be related to better maternity care, to better programs of nutrition, to the reduction of prematurity, to comprehensive family services, to en=- couragement through day care centers and otherwise to stimulate the pre-school intellectual development of children. Diagnostic facilities and services must be available to ensure early identification and complete diagnosis of the retarded child so that he may receive the kind of treatment and train=- ing he needs. 5. Environmental Hazards The impact of the socio-economic trends on environmental health problems and programs has been well documented. The growth of population, urbanization and the swift emergence of the chemical and atomic age have produced hazards of environmental contamination in our air, water, and food that pose a monumental challenge to the community and the nation. Consider= ing what has happened in the recent past, changes in health programming to provide greater emphasis to environmental health hazards will be an important future development in the health field. These are some of the problems that face our nation today. They affect the manpower requirements, the needs for facilities, the kinds of services, and the avenues of future investigation. COMMUNITIES: PLANNING FOR HEALTH AND WELFARE SERVICES Existing community services are, with few exceptions, inadequate in scope, variety, and quantity. For example, only 208 communities in the United States have homemaker services available, and agencies providing homemaker services are concentrated in less than half the States. Although visiting nurse services are more generally available, about 30 percent of the cities with populations of 25,000 or more are without such services. About half of all the counties in the United States do not have full-time public child welfare services available. More than half of the nation's counties fail to offer probation services for juveniles. Even the juvenile courts that do have probation services are inadequately staffed with pro- bation officers, and only one-tenth of these juvenile probation officers have full specialized training. The advancement of improved community planning is a responsibility shared by all three levels of government. Responsible community leaders should initiate and carry out vigorous action to solve social problems of highest priority in their own locality Federal and State Responsibility Cities and even States are typically unable to tap all the taxable resources of a State or region in proportion to the social welfare responsi=- bilities they must assume, or in terms of the different kinds of wealth a that the nation produces. Tax programs involving appropriate State and Federal participation need to be developed which tax resources equitably and distribute funds to meet the urgent social needs of cities. 52 The Federal role is one of leadership, stimulation, and selective assistance. This role may include helping States and communities to identify the needs involved in the changing socio-economic framework. The Federal government should sponsor research to develop basic knowledge on emerging community problems. It should stimulate and provide incentive for area-wide planning demanded by the growth problems mentioned above. One possible way of achieving this end is to condition the availability of grants for com- munity facilities or programs on the requirement that they be fitted into an overall area-wide planning effort. The Federal government must be concerned with the availability of the basic resources--the manpower and facilities that are required by the program growth envisioned in the next few decades=--by supporting and stimu- lating training and education in areas of manpower shortage in the helping professions, and through a balanced program of construction grants to State and local governments. The primary State responsibility should be to seek out new methods of planning and organization in helping the new suburban communities as well as the old central cities to cope with new and increased burdens which they cannot resolve themselves. The States can render technical assistance and guidance to communities on the problems in which they have special competence and resources which the individual community does not have. The Role of the Community In setting goals for community services for the future, it is evident that long range planning, at all levels, is needed in order to strengthen preventive services and to break the cycle of self-perpetuating dependency and poverty. Active participation of citizens in services and planning at the community level is essential. Without such participation, the community cannot fulfill one of its most important responsibilities--the assimilation and integration of dependent and disabled individuals and families into the community. Local public welfare agencies, Social Security district offices, health departments, and other public agencies must be prepared to work closely with local planning bodies where they exist and help establish them where they do not, making known the problems as they see them in the operation of their own programs or of other social service programs in the community. Voluntary agencies are involved at all levels of planning for services; one of their most important functions is the encouragement of citizen participation, particularly at the community level. Guides to the Development of Community Services To meet the challenge of the future successfully, the following general principles are offered as guides to the development of community health, welfare, and related services: 1. There should be accessible to the people in the communities where they live a range of community services broad enough to enable individuals and families to cope constructively with their social, physical, emotional 53 and economic problems. Such services should be planned for in such a way that when they reach the individual they do so as an interrelated whole. 2. Services should be available without regard to the individual's race, religious affiliation, citizenship, residence, or income. The cost of such services may be borne by the individual to the extent of his ability to pay for them or by the public depending on the nature of the service and established public policy. 3. A high priority should be given in over-all planning to the health, social, and related services which will strengthen the ability of families and individuals to manage and plan for themselves, which will enable persons to continue to live in their own homes as long as possible, and which will enable those who have had to be cared for in other ways to return to family living where this is feasible. i, Preventive services, those which reduce the incidence of problems requiring community action, should be given a high priority in planning. 5. Care outside the family setting should be available for persons for whom this is appropriate, such care to be provided in a manner which will safe- guard the individual's opportunity for as satisfying and well-rounded life as is possible for him in the light of his particular circumstances. 6. Services should be provided by, or under the direction of, persons fully qualified by professional training to give them. 7. There should be a continuing program of evaluation and research to determine how well the services provided meet the needs of People, and to add to scientific knowledge about cause and effect, with a plan for utilizing such knowledge as it becomes available in planning programs of community services, 8. An organized planning and coordinating group is need ed in every community with population of 25,000 or more, and should include broad citizen representation as well as representatives from agencies and organizations, both public and private, providing services. It is clear that community programs will need to be expanded if the objective of services being generally available to people wherever they live is to be met. The local community, where the needs for community services are greatest, may have the least resources for meeting them. The State has a broader tax base than the community and must take its share of responsi- bility for financing and developing community services throughout the State. The Federal government, with the widest tax base and ability to spread the tax burden among the entire population, also has an obligation for appro- priate participation to assure that these needs can be met. The urgent need is for action beginning at the community level to develop more and better services to assure the maximization of each citizen's potential. The social, economic, and health conditions that call for com- munity action are clear and incontrovertible. The contradiction implicit in the existence of culturally and economically deprived minorities in the midst of our increasing affluence must be faced and overcome. There should be citizen participation at all levels in planning and coordinating community services to meet the changing needs of our people. Sh PART II CHANGING POPULATION AND CHANGING NEEDS 56 MARRIAGES, BIRTHS, AND POPULATION GROWTH Anders Lunde, Carl Ortmeyer, and Earl Huyck A noticeable decline in the United States birth rate from a high point in 1957 (25.0) to a new low in 1962 (22.4) has stimulated considera- tion as to the effect this change will have upon the population structure of the United States, and in turn on the organization of the family, on programs concerned with children, on education, on matters pertaining to public health and welfare, and on social and economic life in general. Yet the present decline in the birth rate (live births per 1,000 popula- tion) does not necessarily mean that there will be fewer children born in future years. There is every reason to believe that there will be a continuing high level of births and possibly an increase in the actual number of births toward the close of the present decade and into the next. The outlook is for considerable growth of the United States population. Growth of the Population In the first half of the 20th Century, the population doubled, growing from 76.1 million in 1900 to 150.7 million in 1950. The largest numerical growth in the history of the United States took place between 1940 and 1960 when the population increased by 47.7 million persons, a number almost as large as the total population recorded by the census of 1880. The total population increased by 19.0 million persons in the 1940%s and by an unprecedented 28.6 million persons in the 1950's, Dr. Lunde and Dr. Ortmeyer are in the Natality Statistics and Marriage and Divorce Statistics Branches, respectively, of the National Vital Statistics Division, National Center for Health Statistics, Public Health Service, U.S. Department of Health, Education, and Welfare. Dr. Huyck is a Program Analysis Officer in the Office of the Assistant Secretary (for Legislation). Based on: (1) Vital Statistics of the United States, Monthly Vital Statistics Reports, Vital Statisties--Special Reports, Volume 51, Number 1, Whelpton and Campbell, Fertility Tables for Birth Cohorts of American Women, and unpublished data; (2) U.S. Office of Education, Circular No. 692, K.A. Simon, Enrollment in Public and Nonpublic Elemen- tary and Secondary Schools 1950-80; (3) U.S. Department of Commerce, Bureau of the Census, Series P-20, No. 108, Grabill and Parke, Marriage, Fertility and Childspacing: August 1959; Series P-25, No. 251, Interim Revised Projections of the Population of the United States by Age and Sex: 1975 and 1980; 1960 Census of the Population, United States Summary; and (4) U.S. Department of Labor, Bureau of Labor Statistics, Special Labor Force Report No. 24, Interim Revised Projections of U.S. Labor Force, 1965-75. Health, Education, and Welfare Indicators, March 1963 57 Nor is the end in sight; it is estimated that between 30 and 36 million persons will be added to the total population by 1970, and another 37 to 45 million by 1980, making a total population of 246 to 260 million persons. Births, deaths, and migration are the vital factors which deter- mine the rate at which a population grows. The decline in mortality, extending into the 20th Century, accounted for considerable growth, but the death rate has leveled off in recent years. The decline in the death rate was fairly continuous from 1900 {17.2 deaths per thousand population) to 1953 (9.6), and has fluctuated near that level ever since. GROWTH FACTORS 1931-60 MILLIONS OF PERSONS S50 Net Immigration I Births (IID Deaths a0} 30 Natural Increase 20 1931-40 1941-50 1951-60 Population Growth The flow of immigrants which contributed greatly to growth in the 19th and early 20th centuries was curtailed through the means of the quota system in the 1920's. Despite recent increases in number, net immigration accounted for only about one-tenth of the growth between 1950 and 1960. Nor did the death rate during the decade decline markedly below the relatively low level already attained. Unless an unforeseen catastrophe creates an unusual rise in mortality, or there is a rapid increase in immigration from abroad-- which seems unlikely-- mortality and migration will not be leading factors in population growth during the 1960's and 1970's. The dynamic factor in population growth in the United States is, and will continue to be, the number of births--births of native parentage. Factors in Population Growth (Thousands of persons) Net Natural Estimated Decade population Births Deaths i net civilian growth immigration 1931-40 72953 £1,852 13,849 8,003 -50 1941-50 19,134 31,425 14,237 17,188 1,946 1951-60 27,909 40,689 15.72% ol, 878 3,031 58 Marriages and Divorces The conduct of peace and the waging of war, especially transitions from war to peace, have had considerable impact on marriage trends. Levels of employment and unemployment related to the Nation's economic activity have encouraged or discouraged the taking of marriage vows. Annual marriage totals during the severe economic depression of the 1930's reveal a sharp decline from 1930 to 1933, an equally rapid recovery in 1934, followed by a slower rate of increase through 1937, a sharp drop in 1938, and finally increases in 1939-42 during the period of industrial buildup for defense and war. Large-scale mobilization of men in the marriageable ages has occurred under the serious threat of war as well as during war. Based on analysis of monthly marriage data for 90 major U.S. cities, the deseasonalized number of marriages increased by about 7 percent between March and April 1941 during the peacetime draft preceding United States entry into World War II, dropped off by over 4 percent between April and June 1944 when mobilization for the war was relatively complete, and increased 8 percent from October to November 1945 as the beginning of demobilization brought couples together and permitted them to enter into marriage; the average month-to-month change from 1941 through 1958 was only 1.1 percent. As the pace of demobilization accelerated, the annual number of marriages nationally soared in 1946 to an unprecedented peak of nearly 2.3 million, more than twice as many as the approximately one million marriages annually during the early years (1931-33) of the depression, and about 50 percent greater than the number of marriages in the most recent years, 1960-62. MARRIAGES AND DIVORCES Marriage rate - S— [J | Divorce rate — — 0 i etna a a Le eh yt tdi] — RATES PER 1,000 POPULATION RATES PER 1,000 POPULATION 12 0 1920 1925 1930 1935 1940 1945 1950 1955 1960 1965 1970 59 Following their 1946 peak, marriages declined sharply for three years (13 percent in 1947, 9 percent in 1948, and 13 percent in 1949) to 1,580,000, about the same as thelr 1960-62 levels. During the 1950's fluctuations were smaller--a 5.5 percent rise in 1950, with the onset of conflict in Korea, followed by a general decline (interrupted only by a leveling off in 1953) to a low of 1,490,000 in 1954, a year of economic recession. The level of marriages again rose through 1956, but then dropped to a post-World War II low of 1,451,000 in 1958 during another period of economic recession. Since 1958 there has been some increase. By about 1965 or 1966, when the young people from the "Baby Boom" of 1946-47 reach the late teen ages, there should be a sharp increase in the number of marriages, and it may well be that marriages will again have passed the 2 million mark by 1970. Several factors underlie these marriage trends: The relationship between numbers of marriages and of adult unmarried females; trends in age at marriage; and relative pro- portions of first marriages and remarriages as related to the total number of marriages; and nondemographic factors. The relationship between numbers of marriages and of adult unmar- ried females is indicated by the trend in the number of marriages per thousand unmarried females 15 years of age and over. In general, the number of marriages increases less rapidly than the marriage rate, but the age-sex distribution of the population is such that the marriage rate declines more rapidly than the number of marriages. The year-to- year changes in number of unmarried women 15 years of age and older are relatively less than corresponding changes in the number of marriages. Hence, any decline in marriages is associated with the postponement of some marriages. This "delay" and "catch-up" effect appears for the periods from 1931 through 1939, and from 1954 to the present. The increase in births during and immediately after World War I (resulting in increases in marriageable women about 1940) was sufficient to increase the number of unmarried women almost as rapidly as the number of marriages during the early 1940's. However, from 1945 to 1952, the marriage rate increased less rapidly and declined more rapidly than the number of marriages, indicating that the number of unmarried women was declining--probably due to the unprecedented number of marriages, and because of the declining number of births in the later 1920's and accentuated in the early 1930's. Trends in birth cohorts (groups born during the same years) of marriageable women and in factors resulting in sudden increases or declines in marriages will be reflected in variations in proportions of marriages and in age at marriage. However, percentages of brides and grooms of varying ages and percentages marrying for the first time and remarrying are quite uniform for the years for which data are available (since 1948). The data for 1951-52 show an unusually high proportion of brides and grooms in their early twenties and balancing deficiencies at ages 25 and older. These 1951-52 variations are probably attributable to mobilization of manpower during the Korean conflict. More dramatic 60 changes in numbers of marriages after the mid-1960's as the post World War IT "Baby Boom" children enter peak marriage ages may upset these uniformities, particularly as to age-at-marriage. Divorce, the legal and final rupture of an existing family, doubled in number from less than 300,000 in 1941 to more than 600,000 in 1946. At present about 400,000 marriages are ending in divorce each year. The current divorce rate per thousand population, at about 2.2, is at the 1941 level; the rate in 1946 was 4.3. In terms of married females 15 years of age and older, the divorce rate was 17.9 per thou- sand in 1946 and has been about 9 per thousand in recent years. Births Since 1945 Trends in births have followed trends in marriages but with less pronounced monthly and annual fluctuations. MILLIONS OF BIRTHS UVE BIRTHS AND BIRTH RATES BIRTHS PER 1,000 POPULATION 5 50 o vw 40 Number § 30 20 * Includes adjustments for States not in the birth-registration area prior to 1933 Live births adjusted for underregistration through 1959, registered births only thereafter. LLL Liber nn Lb br Ler bere bri brig de 1910 1920 1930 1940 1950 1960 1970 L Birth rates increased rapidly in the second half of the 1940's; the crude rate rose from an average of 20.2 in 1941-45 to 24.2 in 1946-50. Cohort fertilty analysis has pointed up the significance of the "timing" of births. Births are either postponed or advanced during a woman's lifetime 61 as a result of changing economic conditions, war, and other related factors. In the economic depression of the 1930's, many women postponed births. There was a rise in births beginning in 1940 related to economic improvement which led to a peak of 3.1 million births in 1943. During 1939-45 first births were postponed by younger women while older women were having their first babies that had been postponed during the depres- sion years. After a slight decline from 1943 to 1945 while men were in service, the number of births jumped to 3.8 million births in 1947 (Table), the "Baby Boom" year, following a wave of marriages entered upon in 1945 and 1946. The boom resulted largely from the rise in the proportion of women who became mothers for the first time and continued into the fol- lowing decade. Related to this was the fact that more married women were having a child instead of remaining childless permanently. As compared to 1940 when 26,5 percent of all ever married women aged 15-44 were childless, 22.8 percent of such women in 1950 and only 14.8 percent in 1959 were childless. Total Live Births and Crude Birth Rates, 1945-1962 Year Births Rate Year Births Rate (000's) (000's) 1945 2,755 19.5 1954 4,017 24.9 1946 3,289 25.5 1955 4,047 24.6 1947 3,700 25.8 1956 4,163 24.9 1948 3,538 24.2 1957 4,255 25.0 1949 3,560 23.9 1958 4,204 24.5 1950 3,554 23.6 1959 4,245 24.0 1951 3,751 24.5 1960 4,258 23.7 1952 3,847 24.7 1961 4,268 23.3 1953 3,902 24.6 1962(p) | 4,167 22.4 Through 1951-60, the birth rate was maintained at an average of 24.5, and over 40.7 million babies were born, as compared to 31.4 million for the previous decade. The number of babies added to the United States population during the 1950's was greater than for any previous decade in the Nation's history. This growth continued through 1961, when there were 4.3 million births, but declined in 1962, when there were an estimated 100,000 fewer births than in the previous year. This decline in number will probably continue for two or three years. The decline in the annual number of births is partly related to the age and sex structure of the population. In 1960, for example, there were over one million fewer women in the most fertile age group (20-29) than in 1950. These women represented a smaller proportion of the total childbearing population (31 percent in 1960 as compared to 36 percent in 1950). If women in the 30-39 age groups had their families earlier, they would not be expected to produce as many additional children as in an 62 earlier generation; they and their younger sisters in the 20-29 age group may have borrowed from the future. Not until the sizeable groups of potential mothers now under 20 move into the main chilébearing periods will there be an increase in the number of births. There will be about 5S million more potential mothers in 1970 than there were in 1960, and 36 percent of them will be in their most productive twenties. The crude birth rate will probably continue to decline even after the total number of BIRTH RATES BY AGE OF MOTHER births rises. Since this rate BIRTHS PER 1,000 FEMALES is simply the number of births 300 per thousand population and the base number will increase as a result of population growth, the crude rate will drop if the present high level of births is maintained or even if the number of births increases 200 somewhat. For example, if the number of births in 1970 increases to 4.5 million and the population rises to 215 150 million, the crude rate will be less that it is today, (20.9 as compared to 22.4 in on 80-34 years 1962). om nL ys - 250 20-24 years r° 15-19 years Changes in Family Formation - 4 502 . . 35-39 years The changing pattern of family formation in recent years has involved several as- 40-44 years es ts including the time span Oldiededend Sd LLL lb pec n g D 1940 1950 1962 during married life at which a woman will bear her children, the increase in average family size but the decline of the very large family. Since World War II there has developed a tendency to marry earlier and have the first baby sooner after marriage. The median age of mothers fell from 23.0 years at the birth of the first child in 1940, to 22.7 years in 1950, and 21.4 years in 1961. The second and third child also appeared earlier. This advance of births brought about a concentration of family formation at younger ages. While women born in the period 1886-95 had about one-half of their babies before age 28, the women of 1926-30 probably had two-thirds of their babies before that age. The present trend is toward a continuation of this early family formation. 63 There has been an increase in the average size of the American family in terms of cumulative fertility. In 1940 and 1950 the number of children born per thousand women ever married was about 1,900; in 1959, this number had increased to 2,300. Cohort fertility analysis shows that the number of children produced by American women declined steadily from the cohorts of 1876-80 to those of 1907-11. The cohort of 1880 (which reached age 50 in 1930) had produced 3.5 children per woman while the cohort of 1910 (which reached age 50 in 1960) had pro- duced 2.3 children per woman. Iater cohorts, which have not yet completed their childbearing years, have already exceeded the latter figure. For example, the cohorts of 1917 and 1918 had produced 2.4 children per woman by age 40; that of 1919, 2.5 children by age 39; and that of 1920, had borne 2.6 children by age 38. The average number of children per woman is expected to continue to increase through the next decade, but in terms of total women such an increase will probably be less than one child per woman. An increasing proportion of couples are having moderate sized families of two to four children instead of the somewhat smaller families of the 1930's and early 1940's. The large family of five or more children has been on the decline. The BIRTH RATES BY LIVE-BIRTH ORDER cohorts of 1886-90 by ages BIRTHS PER 1,000 FEMALES 45-49 produced 877 fifth or 50 higher order births per thousand women while the Ist child cohorts of 1906-10 produced 391 such births, or a drop of 55 percent. It is antici- pated that the proportion of families having five or more id a = children will continue to 2d child decline through the next decade, 20 Major Demographic Developments in Process a 4th child As a result of the fer- rw mm tility pattern established Br 7h hid since World War II, the stage is already set for three major demographic developments which will have ascertainable effects in the population structure to the end of the century. 3d child Lederer repre 1940 1950 1962 The first of these developments we are now experiencing: the impact upon society of the sheer number of babies born since World War II. The large contingent of babies born in 1947 will attain their 18th birth- day during 1965 and the sizeable groups of the years following 1947 will 64 enter society at different age levels in their turn, for years to come. For example, the educational requirements already imposed by this group on our primary and secondary school systems will soon become the pressures on the colleges and on all phases of our social and economic life during this and the next decade. The second development will result from the fact that most of the postwar babies will reach maturity and eventually marry. The number of marriages which will result by 1970 (if 1960 marriage rates for women continue during the 1960's) has been estimated at about 2.1 million. The fastest rate of increase should appear in 1965 and 1966 when the still-living girl babies of 1946 and 1947 reach the peak marriage ages of 18-20. Since teen-age brides characteristically marry grooms two to four years their seniors, while brides of 21 or older most often marry grooms the same age, some of the young women who were born during the postwar "Baby Boom" may delay marriage for a few years, thus delaying somewhat the years of sharpest increase in the level of marriages. Increased numbers of persons entering marriage will generate another increase in the number of children born. If an increase in the number of marriages may be anticipated during the latter half of the present decade and continuing into the next, we may also expect an increase in births, especially after 1970. The meaningful projection of births is complicated by many factors, not the least of which is the increasing importance of family planning. Yet even should more couples limit the size of their families in the future, there will be an impressive number of children born in the United States due to an increase in the potential number of parents. These three events are interrelated; a cycle has been established wherein the increase in births after World War II results in an increase in marriages and a new wave of births. Fertility Differentials The long standing differences between the fertility rates of whites and nonwhites have been particularly in evidence since World War II. The nonwhite population increased from 13.5 million in 1940 to 20.5 million in 1960, or 52.3 percent as compared to 34.4 percent for the whites in the same period. This was largely the result of the higher fertility of nonwhite women as well as an improvement in life expectancy. In contrast to the white crude birth rate which reached a peak on 1947, then declined and leveled off until 1957, the nonwhite rate continued to rise until 1956, when it was 33.9 per thousand population. In 1961, a record number of 667,000 nonwhite births was recorded at the rate of 31.6 births per thousand population. In that year the fertility rate per thousand white women 15-44 was 112.3 and for nonwhite women was 153.8 (Chart). 65 RATE BIRTHS PER 1,000 FEMALES AGED 15-44 YEARS’ RATE 170 170 A — —— — — 160 {EQ [remem wis 150 140 120 110 100 90 80 *Live births adjusted for underregistration through 1959, registered births only thereafter 70 T - - - 70 Lunn Tre Duesahoasua and) 1910 1920 1930 1940 1950 1960 1970 This fertility differential will continue and affect an increase in the proportion of nonwhites in the community. Negroes constituted 9.8 percent of the United States population in 1940; 10.0 percent in 1950, and 10.6 percent in 1960. By 1970, should the proportion increase to 11 or 12 percent, there will be some 25 million Negroes in the United States. A considerable increase of nonwhite youth in the 1960's and well into the 1970's will exert proportionally greater pressures than the whites in the areas of education and employment. In general, other fertility differentials are smaller than they were a few decades ago. Because of the greater increase in the fertility rate in the urban areas, the urban-rural differences are not so great as they were in 1950. The differences between the geographic regions of the United States are diminishing. Differences in fertility by socio-economic status associated with such factors as education, income, place of resi- dence and occupation likewise have been reduced. The decline in fertility differentials signifies that there has been a trend toward greater conformity in fertility desires and performance throughout the country. Contributing to this decline have been an increas- ing movement toward the cities, an extension of education, a marked improvement in the general standard of living of the population, and an increase in the extent and effectiveness of family planning. Births and the Population Structure The dynamic factor of increased births will dramatically alter the population structure with far-flung consequences in the social and economic life of the United States. The population pyramids of 1940 and 1960 show the changes in the age and sex composition of the population in five-year groups wrought in that twenty year period (Chart and Table). The 1960 pyramid is shaped like a dumbbell, broad at the younger and older ages and constricted in the young adult ages. The major difference between the pyramids lies in the base, which changes from a constrictive form in 1940 to an expansive form in 1960. This reflects past growth and future gain through fertility. The children under 15 years of age represented 31 percent of the entire population of 1960, compared to 25 percent in 1940. The increase in the population 35 years and over is apparent. Persons aged 65 and over represented 7 percent of the popula- tion in 1940 and 9 percent of the population in 1960. The illustration shows the possible structure of the population of 1980 superimposed upon the structure of 1960. The enlarged base indicates a strong future growth potential, with a considerable enlarge- ment of all groups up to 40 years of age. The somewhat constricted 40 49 group represents contingents born during the low birth periods of the 1930's. The age group 50-54 is substantially larger, representing the greater number of births in pre-depression years. The enlarged group 75 and over represents increased life expectancy. Anticipated fertility increases will create a younger population in the United States. The median age of the population increased during every decade from an estimated 16.7 years in 1820 to a peak of 30.2 years in 1950. In 1960 the median age dropped to 29.5; the current decline will continue in this decade and into the next. Changes in Age Structure of the Younger Population The population changes that have made their impact during the two past decades and which will affect the future may be understood in terms of the alterations in the numbers of persons of varying ages under 20. Children under 5 years of age doubled in number between 1940 and 1960 from 10.5 million to 20.3 million (from 8 percent to 11.3 percent of the total population), and should grow even larger into the next decade, possibly to 25 million by 1970. 67 Children 5 to 14 years totaled 22.4 million in 1940 and 35.5 million in 1960. They contributed to the pressure on the elementary schools and are now entering the secondary schools. This age group by 1970 may total some 40 million and after 1975 will increase substantially with the entrance of children born in the late 1960's. Children 15-19 years, numbering 10.6 million in 1950 and: 13.2 million in 1960, will increase in number until the middle of the next decade at least. The early "Baby Boom" children are entering the age group now, and the high birth years of the recent past will tend to swell it as time goes on. As a whole, persons under 20 years of age numbered 45.5 million in 1940; 51.1 million in 1950; and 69.0 million in 1960. According to Census Bureau projections, this number will increase to about 87 million in 1970 and to 109 million in 1980. In the next ten to twenty years, therefore, there will be greater demands placed upon our educational facilities, and we may expect an increase in those problems which deal with dependency, child care, and youth. The mere bulk of the projected group will portend an increase in the number of younger persons involved in delinquency and crime, and other marginal anti-social activities. There will likely be an increase in the number of illegitimate births. Implications for Education From kindergarten through college, the schools may expect an invasion from the younger populations which have been building up since World War II. Between 1949-1950 and 1959-1960, total school enrollments in kindergarten-grade 12 increased from 28.6 million to 42.4 million, or about 48 percent. The average enrollment growth in kindergarten-grade 12 was 1.4 million children per year. Total school enrollment growth is expected to range between 10 and 15 million in this present decade, and to be between 12 and 17 million in the 1970's. There were 22.2 million children enrolled through 8th grade in 1945.50 and 32.8 million in 1959-60. Projections show this group increasing to 39 million in 1969-70 and to about 49 million in 1979-80. The secondary school enrollments did not grow as fast in the last decade but their growth is accelerating as the large birth contingents come of age. Some 6.4 million children were enrolled in secondary schools in 1949-50; 7.7 million in 1955.56, and 11.5 million in the fall of 1962. Medium estimates show that this group will increase to 14 million by the end of this decade and to around 17 million in 1979-80. At the end of World War II, about 80 percent of all persons 14- 17 years of age were enrolled in school; by 1962, 92 percent were enrolled. This emphasizes a rather steady increase in the proportion of persons of this age group who enroll in school. Rising economic demands for trained manpower coupled with individual aspirations are augmenting the population factor, and will continue to do so in the future. 68 The college age group, 18-21 years of age, will grow relatively rapidly in this decade. Rising college enrollments will continue to increase--and sharply after 1965. Population growth is perhaps the most significant factor, but the growing interest in college study is also involved. College enrollments were estimated at 2.2 million in 1950 and 4.2 million in 1962. Projections indicate that some 8.5 million students may be enrolled in colleges and universities in the academic year 1972-73. There has been an increase in the number of persons enrolled in federally-aided vocational courses of all types, from 2.8 million in 1948 to 4 million in 1962. The great mass of young persons who will not enter college and who may not find immediate employment after high school may turn to vocational schools in larger numbers. We may therefore anticipate that this type of school may be under considerable pressure beginning the last half of this decade. Increasing interest in adult continuing education--of training and retraining--may also be anticipated. The Productive Age Group: Implications for Employment Persons between the working ages of 20 and 65 increased from 77.3 million in 1940, to 87.3 million in 1950 and to 93.8 million in 1960. Because of the entrance in the near future of persons born after World War II, persons of this age group will grow to about 107 million in 1970 and possibly to 127 million in 1980. Despite the postwar increase in numbers, the proportion of the population in the group declined from a peak of 57.8 percent in 1945 to 52.3 percent in 1960. The decline will continue through this decade and into the next as a result of the shift in age distribution, from an older to a younger population seen as a whole. The labor force has nonetheless grown from 53 million persons in 1940 to 72 million in 1962. Iabor force projections indicate a further increase to 86 million in 1970 and 93 million in 1975. The most dramatic increase will be in younger workers under 25 years of age. They will be entering the labor force in a period of accelerated technology applied to clerical as well as to production processes. A more significant role in the labor force will be played by women as a result of two factors--a larger number of young women as well as men will be seeking work in the late 1960's, and family completion at earlier ages will release more women from family duties. The full effect of the latter phenomenon will probably not be felt until the late 1970's. A bi-modal pattern has already been established of work, family formation, and return to work to pay for rising levels of living andl to put a through college. Between 1950 and 1960, more women than men were added to the work force, 4.8 million women as ’ compared to 3.5 million men. The number of women in the labor force rose from 18.7 million in 1950 to 23.5 million in 1962 and may reach about 30 million in 1970. The Older Population Persons 65 and over numbered 12.3 million in 1950; 16.6 million in 1960, and are expected to increase to about 20 million in 1970. The position of this group has been discussed in Health, Education and Welfare Indicators (November 1962, January and March 1963) in three articles: "The Older Population," "New Horizons for the Aged," and "Medical Care for the Aged under Public Assistance." POPULATION BY AGE AND SEX Mole i FO h : | . scHooL CHILDREN | ; [ ] [ BY | pre-scHoou| i 6 5 4 3 2 1 0 | 2 3 4 S 6 “ 13 12 Nn 2 13“ MILLIONS MILLIONS Population by Age and Sex (in millions) 1940 1960 1980% obs Males Females Males Females Males Females P Number | Percent | Number | Percent|| Number | Percent Number | Percent [| Number | Percent | Number | Percent Total 66.3 100.0 65.8 100.0 88.3 100.0 91.0 100.0 128.1 100.0 131.4 100.0 — — ee ee po mmm me se fw Ri hemor aos ae i ae 0-4 5.4 8.1 5.2 1.8 10.3 11.7 10.0 11.0 16.6 13.0 15.9 12.3 5.9 5.4 8.2 5.3 8.0 9.5 10.8 9:2 10.1 14.7 11.5 14.1 10.7 10-14 6.0 9.0 5.8 8.8 8.5 9.7 8.2 9.1 12.9 10.1 12.3 9.4 15.19 8.2 9.4 6.2 9.4 6.6 7.5 6.6 7.2 11.4 8:9 10.9 8.3 20-24 85.7 8.6 5.9 9.0 5.3 6.0 5.5 8:1 10.3 8.1 10.2 7.3 25-29 5.5 B.3 5.6 8.6 5.3 6.0 5.5 6.1 9.6 7:5 9.5 7.2 30-34 5.1 Te 5.2 7.9 5.8 6.6 6.1 6.7 8.7 6.8 8.6 6.6 35.39 4.8 7.2 4.8 7-3 6.1 6.9 6.4 70 6.9 5.4 6.9 5.5 40-44 4.4 8.7 4.4 6.7 5.7 6.4 5.9 6.5 5.6 4.4 5.8 4.4 45.49 4.2 6.4 4.1 6.2 5.4 8.1 5.5 6.1 5.4 4.2 5.6 4.3 50-54 3.8 5.7 3:5 B+35 4.7 5.4 4.9 5.4 5.6 4.4 6.0 4.5 55.59 3.0 4.6 2.8 4.3 4.1 4.7 4.3 4.7 5.5 4.3 6.1 4.6 60-64 2.4 3.6 2.3 3:5 3.4 3.8 3.7 4.1 4.7 3.6 5.4 4.1 65-69 1.0 2.9 1.9 2.8 2.9 3.3 3.3 5.7 3.8 3.0 4.7 3.6 70-74 1.3 1.9 1.3 2.0 2.2 2.5 2.6 2.8 2.8 2.2 3.7 2.8 75+ 3.2 1.9 1.4 2+1 2.4 2.7 5.2 3.5 3.7 2.9 5.7 4.3 % Source: U.S. Department of Commerce, Bureau of the Census; Current Population Reports, Po ulation Estimates, Series P-25, No. 251, ‘'Interim Revised Projec- tions. . .,"" July 1962. Projection Series II assumes that fertilicy ot continue at the 1955-57 level (which remained about the same through 1958-60) throughout the projection period to 1980. 70 INVESTMENT IN HUMAN RESOURCES I. Economic Report of the President On January 20, 1962, the President presented his Economic Re ort to the Congress, as required under the Employment Act of 1946. With his Report the President transmitted the Annual Report of the Council of Economic Advisers. A portion of the Council's Report is devoted to "Investment in Human Resources" and to the relationship of expenditures on health and education to economic growth. The following are extracts from the Council's Report: Increased production is not an end in itself but only a means of pro- viding increased real income for all to share.... High levels of education and health, equality of opportunity--these are among the valid measures of a society's performance. They are desirable in their own right. In addition, they have an economic dimension. They are among the foundations of growth as well as among its benefits. Americans have long spoken of foregoing consumption today in order to invest in their children's education and thus in a better tomorrow. For an economy, Just as for an individual, the use of the word invest in this con- nection is clearly justified, since it is precisely the sacrifice of consump- tion in the present to make possible a more abundant future that constitutes the common characteristic of all forms of investment. That devoting resources to education and health is, in part, an act of investment in human capital ex- plains why programs in the area of education and health are economic growth pProgramsee so Failure to pursue vigorous educational and health policies and programs leads to smaller increases in output in the long run; it is also associated with higher expenditures in the short run. If we fail to invest sufficiently in medical research, we lose not only what stricken individuals might have produced had they been well, but also the use of the resources and funds cur- rently devoted to their care. Fallure to invest sufficiently in education means that we will lose the additional output that would be possible with a better educated labor force; it may also mean the perpetuation of social pro- blems necessitating public expenditures.... Education Estimates made by private scholars suggest that about one-half of the growth in output in the United States in the last 50 years has resulted from factors other than increases in physical capital and man-hours worked. Edu- cation is one of the "other factors." Even without allowance for the impact of education on invention and innovation, its contribution appears to account for between one-fourth and one-half of that part of the increase of output between 1929 and 1956 not accounted for by the increased inputs of capital and labore... ° Health, Education, and Welfare Indicators, March 1962 Revised 1963 1 Though significant progress has been made, substantial opportunities and needs for investment in education still exist. There is a pressing need to improve curricula and teaching methods, make education more readily avail=- able to students of merit by reduction of financial barriers, expand facili- ties and staff to meet rising enrollments, improve the quality and productiv= ity of our teaching staffs and increase their salaries, and narrow the gap in opportunities available to students in different parts of our country. These problems must be met--and met quickly--at all levels of government and at all levels of education if our standards of education are to keep abreast of our needsS.eee Enrollments in elementary and secondary schools rose from 28.2 million pupils in 1950 to 46.7 million in 1963. Enrollment in 1970 is expected to be 53.2 million. In 1950, 2.3 million students were enrolled in institutions of higher education, and by 1962 the figure had risen to 4.6 million. The pro- jected 1970 enrollment is 7.0 million. Rising enrollments have necessitated substantial expansion of personnel and facilities. Further expansion is re- quired if quality is not to deteriorate. Our educational system thus confronts unprecedented challenges. To provide for additional students, replace obsolete structures, and modernize usable buildings, institutions of higher education should invest an average of $2.3 billion annually. Expenditures currently fall short of this by $1 billion. Needs at the below-college level must also be met, lest the founda- tions of the educational system be eroded. The price of failure will be the irrevocable loss of valuable talent. However urgent the need for additional facilities and for the rehabili- tation and replacement of existing facilities, the personnel problem is es- pecially acute, because of the time required to train teachers. In the fall of 1962 about 83,000 full-time teachers in public elementary and secondary schools--some 5.5 percent of the total teaching staff--failed to meet full State certification standards. Demand for new teachers and for replacement of those leaving the profession will be very high. It can be met only by the training of new teachers accompanied by programs to increase the productivity and quality of experienced teachers. Teachers! salaries at all levels must continue their recent rise if good teachers are to be attracted into and re- tained in the profession of educating the Nation's youth... Health U.S. economic growth in the twentieth century has been associated with better health of the population as a whole as well as an increase in per capita expenditures on health and medical care.... At the same time that economic growth has contributed to an improve- ment in the health of our people, better health has contributed to economic growth, Better health makes possible an increase in the size of the labor force and in the effectiveness of effort on the job, 2 Further improvements in health would yield significant economic, as well as human, benefits. On an average day in 1962, 1.3 million employed persons--2 percent of civilisn employment--were absent from work because of illness or accident. The days of work lost because of illness far exceeded the days of work lost because of industrial disputes; in fiscal year 1962 "currently employed" persons lost a total of 394 million days from work as a result of illness or injury, while the loss from industrial disputes in 1962 totaled 19 million days. The costs of ill health have traditionally been calculated as the money spent for the prevention and treatment of accident and disease. The waste of human resources and the consequent loss of production is an impor- tant additional cost about which not enough is known. Where facts are avail- able, as in the related area of vocational rehabilitation, the relationship between costs and benefits is impressive. In 1962, at an average cost of $1,000 per rehabilitant under Federal-State programs, mean wages of rehabili-~ tated persons were raised from $8.70 a week at acceptance to $41.20 at closure, a difference of $32.50 a week after rehabilitation. Public support for medical research, the most basic of investments in better health, has been growing. In fiscal year 1963 the Federal Government will provide about two-thirds of the $1.5 billion in national expenditures for medical and health-related research. Further expansion of research activ- ities, where funds can be wisely spent and where qualified research personnel exist, is desirable both for humanitarian and economic reasons. Much of the necessary research is carried on by doctors of medicine. More rapid expansion of the number of physicians is required to insure that patient care needs, teaching needs, and research needs can all be met. This will be true even if needed improvements are made in the organization and financing of medical care. Increased demands for medical services, stemming in part from new dis- coveries and in part from growth in population and changes in age and income structure, already mean unfilled internships and residencies in hospitals. The full medical needs of the country are not being met in many fields, in- cluding public health and preventive medicine... Eliminating Racial Discrimination Racial discrimination....inflicts immeasurable human and social costs on a large number of our citizens. In addition...it inflicts an economic oss on the country. Discriminatory practices in education, training, employment and union membership impede the development and utilization of human resources. They reduce the efficiency and slow the growth of the economy, at the same time that they alter--and alter inequitably--the distribution of the fruits of economic progress. Although significant reductions in discriminatory barriers have been accomplished in recent years, important problems remain. Many nonwhite families are trapped in a vicious circle: Job discrimination and lack of 3 education limit their employment opportunities and result in low and unstable incomes; low incomes, combined with direct discriminations, reduce attainable levels of health and skill and thus limit occupational choice and income in the future; limited job opportunities result in limited availability of vocational education and apprenticeship traininge.se. II. Economic Effects of Programs Administered by the Department of Health, Education, and Welfare 1/ The Department of Health, Education, and Welfare administers some 112 pro- grams that have as their aim the development and improvement of the well- being of the American people. And, because of the importance of human resources to national strength and national development, the programs of the Department help to strengthen the economy in several ways. These programs: 1. Prevent or reduce illness, disability, and premature death. These programs serve to extend the productive years of life and to decrease time lost from work and school because of sickness or injury. The community health services, maternal and child health, crippled children's, and the accident pre- vention programs are in this category. 2, Increase our knowledge of the causes of illness, of mental retarda=- tion, of the learning process, and of the causes of delinquency and dependency. These are the research programs of the National Institutes of Health, the Office of Education, Office of Vocational Rehabilitation, and Social Security Adminis- tration, that will pay large dividends in years to come, as they have in the past, in lower death rates, in more effective methods of dealing with sickness and disability, in higher quality of education, and in a reduction in dependency. 3. Extend the availability of health services and the facilities, equip- ment, and supplies needed for medical care. Medical care payments under the public assistance program, the chronic disease programs, the Hill-Burton medi- cal facilities and construction program, and the new community facilities pro- gram enacted last year, are in this category. 4. Promote the rehabilitation to productive living of individuals who because of injury, illness, congenital deficiency, or other defects are in need of restorative treatment. These programs include vocational rehabilitation and those that seek to help the drug addict, the alcoholic, and delinquent, and the many others who, because of physical, mental, or emotional problems, are unable to contribute constructively to society. 5. Contribute to the conservation and development of natural resources and to the safety of the environment. These are the programs directed to the problems of the pollution of water and air and the control of radiological hazards to health. 1/ Based on the testimony of the Secretary of Health, Bducation, and Welfare before the Joint Economic Committee of Congress, January 31, 1962. Th 6. Protect the consumer by insuring a safe supply of foods, drugs, and cosmetics. These programs are administered by the Food and Drug Administration and the Public Health Service. To Contribute to the size, quality, mobility, and productivity of the labor force. In general, these same programs promote opportunity, en- hance the earning power of individuals, and add to the income stream of the Nation. They include such Federal aid to education programs as the National Defense Education Act, vocational education, and training programs to in- crease the supply of research workers, nurses, and other health, education, and welfare professions. 8. Extend the quality and availability of educational services, facilities, equipment, and supplies. These programs include grants for teacher training; for guidance, counseling, and testing; for the strengthen- ing of science, mathematics, and modern foreign language instruction; and for specified educational institutions, such as Howard University and the land-grant colleges. 9. Provide income payments to retired, disabled, and dependent persons. The old-age, survivors, and disability insurance program now covers almost 90 percent of all paid employment in the United States. Tt provides bene- fits to retired workers and their dependents, to permanently and totally dis- abled workers and their dependents, and to surviving dependents. 10. Provide assistance to needy persons. The Federal Government shares in the cost of assistance of four categories of needy persons: the aged, the permanently and totally disabled, the blind, and children in need because of the death, desertion, absence, or unemployment of the parent. From the many programs that fall under these headings two--consumer protection and vocational rehabilitation~-might be singled out as illustrative of the economic impact of DHEW programs. Economic Effects of Consumer Protection The Food and Drug Administration's principal consumer protection program is the enforcement of six Federal laws designed to assure that foods are safe, pure, and wholesome; that drugs are safe and effective; and that cosmetics and therapeutic devices are safe; and that all of these products are honestly labeled and that hazardous household products bear sufficiently informative labeling to permit their safe use in the home.... These activities have significant economic effects: 1. Without a strong enforcement program it would be easier to market products that were slightly under the weight or volume declared. Consumers spent over $00 billion for food in 1962. If shortages in weight and volume averaged only 2-3 percent (less than + ounce per pound or pint) it would cost American consumers nearly $2.2 billion a year. 75 2. Without a strong enforcement program it would be easier to market foods that are adulterated with less expensive, less nutritious, or with actually injurious ingredients. The adverse effect of many of these prac=- tices on the public health would be great. If such adulteration amounted to but 2-5 percent of the value of the food dollar, another $2.2 billion would be lost to the consumer each year. 3. An active FDA sanitation program has contributed substantially to the decrease in the quantity of foods which are destroyed by insects and rodents esch year. lk, The establishment of food standards has contributed to the quality of food. These standards in turn have helped the general health of the Nation, such as by contributing to the reduction or elimination of certain diseases caused by dietary deficiencies. 5. Strong FDA programs have fostered enlightened food sanitation and carefully controlled food manufacturing practices that have the effect of lowering the annual number of cases of food poisoning in this country. Such safeguards and accomplishments have significantly bolstered public confidence in our food supply. On the whole, the American consumer trusts the food industry and believes that reliable manufacturers are providing good, wholesome products. This public confidence in our foods has several additional economic effects: 1. Though American consumers waste an estimated $500 million annually on nutritional quackery, the figure would be much higher if confidence in the food. supply were lacking. ©, Consumer confidence has led to the widespread acceptance and use of prepared foods and has materially increased the rate at which completely new food industries--such as the frozen food industry--have grown. 3, Widespread use of prepared foods has at least made easier an ever- increasing participation of women in the labor force, Over 24 million women (55 percent of whom are married) now represent approximately 34 percent of the civilian labor force. 4, More adequate diets, fostered in part by general confidence in the food supply and ready availability of a plentiful and varied supply of good food, have contributed to a national health level never before achieved. A healthy population means less man-hours lost because of illness, injury, or death. Other economic effects can be attributed to enforcement of Federsl laws and regulations relating to drugs. About $5.1 billion annually is spent by con- sumers for drugs. The Food, Drug, and Cosmetic Act was strengthened by the Drug Amendments of 1962, which require drug manufacturers to prove that new drugs are effective as well as safe before they may be marketed commercially. The amendments 76 also establish new safeguards for drug research, menufacture, and distri- bution, and broaden the factory inspection authority of the Food and Drug Administration. It would be difficult to estimate what portion of the improved medical picture should be attributed to the activities of the Food and Drug Administration. But there is no doubt that the speed-up in medical research produced earlier marketing of such miracle drugs as anti-infective agents, tranquilizers, anti-hypertension agents, and anti-histamines. These drugs and others have been a major factor in extending productive lifetime, re- ducing the time lost from work through disease, and improving the efficiency of large segments of the population, with great economic gain to the country as a whole€esses Other consumer protection activities, such as the removal of dangerous or ineffective drugs and devices from the market, drug warnings to insure safer employment of drugs, and the advice given to drug manufacturers through inspection and other educational activities, produce other economic benefits.... Vocational Rehabilitation and the Economy Vocational rehabilitation is an outstanding example of investment in human resources that has a direct economic impact. The Vocational Rehabilitation Administration of the Department of Health, Education, and Welfare adminis- ters the grant-in-aid program that assists the States in rehabilitating physically and mentally disabled people so that as many of them as possible may earn their own living and may make their own contribution to the economic welfare of this country. There are in the United States today more than two million disabled people who could through vocational rehabilitation services be able to work either in the competitive labor market, in sheltered employment, or in their own homes, Of the persons who become disabled each year, over 270,000 could benefit from vocational rehabilitation services. The State Vocational Rehabilitation Agencies last year served more than 345,600 disabled people and rehabilitated 102,400 into employment. This year's goal is 110,400 rehabilitations. The following are illustrations of the economic effects of the vocational rehabilitation program: 1. Reduction in Unemployment and Increased Farnings. In fiscal year 1962, over Th,L00 of the 102,400 disabled who were rehabilitated and placed in employment were not employed when their rehabilitation began. The remaining 28,000 were under-employed or employed in unsuitable occupations. Total earnings of these people in the year before rehabilitation was $44 million. It is estimated that the entire group will earn in their first full year of employment $211 million, a gain of $167 million. 2. Publicly Supported Cases Returned to Economic Productivity. About 17,800 disabled people who were rehabilitated in 1962 were being supported by public funds at the time they were accepted for rehabilitation or while receiving rehabilitation services--13,600 were receiving public assistance and 4,200 were in tax-supported institutions, such as mental hospitals. 71 Payments to the 13,600 public assistance recipients cost taxpayers $15.3 million a year before rehabilitation services were provided. After rehabilitation, only 5,370 clients were receiving public assistance of $5.1 million per year--a reduction of over 60 percent in clients and a savings of over $10 million annually in public assistance expenditures. 3. Increase in the Size of the Labor Force. The 102,400 disabled people who were rehabilitated in 1962 alone will contribute 150 million work hours annually. Approximately 8,000 of these rehabilitants are in professional, semi-professional, and managerial occupations. Over 12,000 are in skilled work; 7,500 in agriculture; 16,400 in clerical and sales; 20,600 in services; and the remaining are in semi-skilled and unskilled work. 4, Payment of Taxes by Rehabilitants. It is estimated that the disabled people who are established in employment through the public vocational rehabilitation program will pay, during the remainder of their work lives, about $7 in Federal income tax for each Federal dollar in- vested in their rehabilitation. Vocational rehabilitation embodies a philosophy which the Department is extending to other areas. The concepts of prevention and rehabilitation are being infused to the greatest extent possible into all of the Depart- ment's programs. The objective, as President Kennedy has said, is to "stress services instead of support, rehabilitation instead of relief, and training for useful work instead of prolonged dependency «" 78 PUBLIC AND PRIVATE EXPENDITURES FOR HEALTH, EDUCATION, AND WELFARE, 1953-1963 Wilbur J. Cohen and Ida C. Merriam Totel public and private expenditures for health, education, and wel- fare amount to an estimated $101 billion in FY 1963--an increase of 142 per- cent above the $41.7 billion spent for similar purposes in FY 1953 (Table 1). When adjusted for changes in the price level, the increase over the decade (in fiscal 1963 dollars) is 111 percent. When population growth of almost 30 million persons in this ten-year period is also taken into account, the increase in expenditures per capita and in constent value dollars comes to 78 percent. In the ten-year period 1953-1963, the share of the total output of the U. S. economy devoted to health, education, social insurance and wel- fare has increased substantially. Public and private expenditures for these purposes have risen from 11.6 percent of the gross national product In fiscal year 1953 to an estimated 17.8 percent in FY 1963. In the light >f the other demands on the economy--for defense, for efforts to conquer space, for highways and urban renewal and rising consumption in general-- this is an impressive indication of the importance which the United States attaches to humen values and human needs. In comparison with the primarily public supported expenditures for space, defense, highways, and urban renewal programs, however, expenditures for health, education, end welfare programs continue to derive a substen- tial proportion of their support from private funds. The public share of total health, education, and welfare expenditures is less than two-thirds and showed no increase between 1953 and 1963 (Table 1). Population end Economic Growth Underlying Increasing Expenditures The increase in health, education, and welfare expenditures represents ean expansion of services to a larger population, an increase in the level and scope of services, and a rise in prices. Within the decade 1953 to 1963 the total population of the United States increased by 30 million and reached 166 million. The school-age population, largely concentrated in Mr. Cohen is the Assistant Secretary (for Legislation) end Mrs. Merriem is the Director, Division of Research and Statistics, Social Security Adminis- tration, U. S. Department of Health, Education, and Welfare. For a longer time series beginning with FY 1935, see the Social Security Bulletin, Novem- ber 1962. See also "The Tenth Anniversary of the Department of Health, Education, and Welfare" in this publication for legislative, organizational, and operational changes occurring between 1953 end 1963. Data are given for fiscal years 1953 and 1963 unless otherwise indicated; FY 1963 began July 1, 1962 end ends June 30, 1963. Fiscal 1963 date are advance estimates. Health, Education, and Welfare Indicators, June 1963 9 CHART 1 United States Expenditures for Billions of Dollars i1lions Health, Education, and Welfare, 1953-1963 Biluioms of —~ 3 Total 100 |—- In Constant (1963) Dollars —j0 Private [ Public / Heal tt. Social 1! Education 50 Insurance |! and Welfare / Health Education 25 + Welfare a kd 0 1953 1963 1955 1963 1953 1963 1953 1963 Health, Education, and Welfare Trends the 5 to 19 age group, rose from 38 million to 53 million, and the elderly population aged 65 end over increased from a little over 13 million to 17.5 million. Urban areas absorbed the population increase--the rural population actually declined. With this farm-to-city shift, problems of health, education, and welfare have become concentrated in urban-suburban areas. The simulteneous growth of the American economy is reflected in the increase in gross national product (in constant 1962 dollars) from $416 billion in 1952 to $554 billion in 1962. Per capita disposable personal income (in constant 1962 dollars) rose from $1,736 to $2,051 in the interim. The cost of living, as measured by the consumer price index (1957-59=100), rose from 93.2 in 1953 to 106.0 at the beginning of 1963. Expenditures for health, education, and welfare are not dollars spent in a vacuum. Rather they help the individual to remain healthy and to de- velop the skills essential to a space-age economy and at the same time express society's concern for the individual and his family. Economic growth depends not only upon investment in factories and research facili- ties, but also upon investment in human skills and services. Our economy has been able to sustain and increase expenditures in human resources, 80 x which in turn provide the stimulus for further economic growth. High levels of education and health are among the foundations of eco- nomic growth as well as among its benefits. Education has made a signifi- cant contribution to growth in output in the United States in the last 50 years. Remaining in good health can cut absenteeism from work; rehabili- tating the disabled can add to the Nation's production. Conversely, the failure to make such investments may mean the continuation of "functional illiteracy"--low educational atteinment limiting adaptability to changing requirements for employment--and the continuation of expenditures for the current care of the ill and disabled without realizing a return from their productive employment. There has been a growing recognition of the function of health, educa- tion, and welfare programs in a modern industrialized economy. The shift from an agricultural society to a complex technological economy based on the division of labor and a money-and-credit system of distributing income and the accompanying shift from the extended family to the small unitary family heave necessitated a parallel shift in the basis for income support and the services needed by both productive and nonproductive groups in the population. The skills and competencies required in a technologically TABLE 1 Distribution of public and private expenditures for health, education, and welfare, fiscal years 1953 and 1963 Total expenditures Per capita expenditures TTRndis Billions of dollars Dollars Percent Expenditure distribution PR Percent Pavcent? Ee categor 1 ¥ 1953 1963 increase Ne 19¢€3 increase ” Current |Constan Current Constant ¥ 1953 1963 TOTAL (ret)? CHEERY 41,7 47.8 100.9 111 239 297 529 78 100% 1009 Public. svwmnp omens s 26.4 30.3 65.9 118 164 88 346 84 63 64 Privatecoeevsvuss snes 15.8 18.1 36.6 102 98 113 192 72 37 36 BEAL usa uvnnnnvonencs s 15.6 17.9 33.8 89 97 uy 177 59 100 100 Publicesvovmnnmenvse 4.1 4,7 8.5 81 25 29 44 53 26 25 Private.cessnsesswine 11.6 13.2 25,3 91 72 82 133 61 74 75 12.1 13.9 27.8 100 75 87 146 68 100 100 10.1 11.6 22,1 90 63 72 116 61 83 80 Privatesssecvsvaveave 2.0 2.3 5.7 145 12 14 30 107 17 20 SOCTAL INSURANCE AND WELFARE ,.vuevnencee 14.5 16.6 41.1 147 PC 103 216 109 100 100 Public ccss sos tnainne 12.2 14.0 35.3 152 76 87 185 113 84 86 PrivatBecssssesshimen 2.3 2.6 5.8 121 14 16 30 87 16 14 1/ Converted to constant (fiscal 1963) dollars by the Social Security Administration on the basis of implicit price deflators for personal consumption expenditures (1954= 100) developed by the National Income Division, Department of Commerce. The deflator for fiscal 1953 is 98.5 and for fiscal 1963 is an estimated 113. 2/ In constant (fiscal 1963) dollars. 3/ The duplicated total was used as a base to show the approximate distribution between public and private expenditures. The duplicated total of $102.5 billion in FY 1963 was only 1.6 percent above the unduplicated or net total of $100.9 billion; the difference in FY 1953 was only|1.5 percent ($48.5 billion vs. $47.8 billion). 4/ Total and private expenditure amounts adjusted to eliminate duplication resulting from use of cash insurance benefits to purchase medical care and educational services. 1/ The article on "Investment in Human Resources,” contained in Health, Educa- tion, end Welfare Indicators for March 1962 and condensed in New Directions in Health, Education, and Welfare, includes: (1) the Council of Economic Advisers’ statement on such investments and (2) a summary of the economic effects of programs administered by the Department of Health, Education, and Welfare. 81 developed society give new importance and new character to education and educational services. Science has transformed medical care from a personal art into a highly organized and multi-faceted discipline. Urban and sub- urban living have created new demands for socially organized health and welfare services. Rising levels of living have brought to the fore the problems of groups with special handicaps or unusual needs and made possible a variety of special services for them. Social Security Administration Series on Health, Education, and Welfare Expenditures This expenditure series,as developed by the Social Security Administra- tion, focuses on those programs and expenditures that directly benefit in- dividuals and families. The public programs in this series (Table 3) in- clude many administered by other Departments of the Federal Government as well as some exclusively State and local programs. Retired persons, dis- abled earners, and widows and orphans have sources of support--private savings and investments, help from relatives and friends--that are not iden- tifiable in any statistics of total income flows. The total spent under organized income-maintenance end welfare programs, however, can be measured. The satisfactions and well-being of the people are also significantly affected by the state of the economy and the availability of jobs, by the degree of crowding and the adequacy of mass transit facilities in our large cities, by the degree of air pollution and the purity of the water supply. Programs with such general objectives such as air and water pollution are excluded, however. Expenditures for public health control activities and consumer protection (Public Health Service and the Food and Drug Adminis- tration) and for medical reseerch are included because of their importance to personal health care. Total, and total private, expenditures for health, education, and wel- fare are net figures. Data from family surveys provided the basis for the elimination of the duplication in private and in public-private outlays arising from the use of income maintenance payments (under both social insurance and private employee benefit plans) for the purchase of health and educational services. The overlap precludes the precise division be- tween public and private expenditures. Nonetheless, the duplicated sum of all expenditures exceeds the unduplicated sum by less than two percent. Health, Education, and Welfare Expenditures by Category Between 1953 and 1963 dramatic increases occurred in each of the major categories. The largest increase was in social insurance. As a result by 1963 social insurance and welfare accounted for two-fifths of the total, health for one-third; and education for the remainder of total expenditures for health, education, end welfare. In constant (fiscal 1963) dollars: 82 . Health expenditures increased 89 percent from $17.9 billion to $33.8 billion . Expenditures for education doubled from $13.9 billion to $27.8 billion. . Social insurance and welfare expenditures rose 147 percent from $16.6 billion to $41.1 billion. Per Capita Expenditures for Health, Education, and Welfare In constant (fiscal 1963) dollars, per cepita expenditures for health, education, and welfare have increased 78 percent from $297 to $529 between 1953 and 1963 (Teble 1). By category (in constant 1963 dollars): . The average expenditure per person in the United States for health increased 59 percent from $111 to $177. . The per capita expenditure for education increased 68 percent from $87 to $146. . The per capita expenditure for social insurance and welfare more than doubled from $103 to $216. Public-Private Comparisons of Health, Education, and Welfare Expenditures During the decade 1953-1963, total public expenditures for health, education, and welfare have increased somewhat more rapidly (118 percent in constant dollars) then private expenditures (102 percent). Nonetheless, the ratio between private and public expenditures for combined health, education, and welfare has remained fairly constant, with $1 in private funds expected for approximately each $2 of public funds. The relative size of public and private expenditures differs substan- tially in the three major categories (Table 2). In 1963 the public sector accounts for 86 percent of social insurance and welfare expenditures, and 80 percent of educational expenditures, but only 25 percent of health ex- penditures. The public sector share has increased somewhet in social in- surance and welfare (from 84 percent) but has decreased in education (down from 83 percent) and remained approximately the seme in health. This changing public-private relationship was almost entirely the result of growth in the social security system. At the end of 1962, some 63.1 million persons--nine out of ten persons in paid employment--were in Jobs covered or eligible for coverage under the old-age, survivors, and disability insurance program. Ten years earlier 51.2 million persons-- four out of five--had such coverage. In terms of the population aged 65 and over, 78 percent were eligible as workers, wives, or widows; and Tl per- cent were receiving benefits at the end of 1962. The number of OASDI 83 TABLE 2 Public and private expenditures for health, education, and welfare (In millions) Program or activity 195% 1963Y Total expenditures, net? oh SAAN SEAR CRASS EN Yee HEALTH=--Total expenditureB8....esecececescceccsccscsssccssecccsascncse Public expenditureS.eccecescccecseccscccsscccssssccacccscscscccsancne Health and medical serviceS.eccecececccsccsccsesocccncane eee General medical and hospital care--civilian programs. Defense Department and Medicare programs....ceeeccceece Veterans' hospital and medical care...... Public assistance cesesceresessescessassnnnn Workmen's compensation and TDI medical benefited oe Medical vocational rehabilitatioNe..ecececececcecccces Maternal and child health services... School health.iceeeeeecececssacecnne Medical research....cececeeee Other public health services.. Medical-facilities construction..eccesecccccacees Veterans Administration and Defense Department. ORE verses eesevestrssnseresesssnsesesesnesessssssnssssssvne Private eXpenditures...eeeeeseecesssessssssensessesesscsccnscccnss Health and medical services. Direct paymentS.eecescessee Insurance benefits..... Expenses for prepayment...... Industrial in-plant services. Philanthrop¥es cavsvevscoevesvnes Medical-facilities construction...... EDUCATION=-~Total eXpenditureS.cececcecececscscseseseasesscocscscnccns Public eXpenditureS.ccecececeecscasecessssssssssassscsssascscscnee Currentiecececscsscecscacese Elementary and secondary? . Higher education other than veterans VeteranS.cceececcsosccesscssccccncsse Constructioneseeceeceesess . Elementary and secondary Higher educatioN.cecesecesesescscscccccscsccccscscsscasccennes Private eXpenditureS.cuicececsseeessccscescescescrscsssssessssnssanse CUrrent.seeeesscscsccecsas Elementary and secondary Higher education........ COnStIUCLiONeseeececeascvsocrsccscscscacocscscsscrcrsensccscccanne SOCIAL INSURANCE AND WELFARE--Total expendi tures® evecestessesccnne Public expenditures. Social inSUraNCeesecesesscsscescscssccssssccnes Old-age, survivors, and disability insurance Railroad and public employee retirement..... CRTC Unemployment insurance and employment service.....csecceccccse Temporary disability insurance and workmen's compensation..... Public assistance (excluding vendor payments)....... Other Welfare..eeeeeeeessceessccscsseccacnncne Vocational rehabilitation...ceececescececccccacscscscscscscanee Institutional and other care, school lunch, and SUrplus fOOd.eeeeeeeecesseacscccseseasasascscssssccassncosce Child welfare ServicCeS....ecseececcecccescscccaccasscsccccscoces Veterans' programs: compensation and pensions and other welfare BervicCeS.ceecceececececsscsoacncscscssnssscsscacsanncss Private expenditpureS..eceecees Philanthropy “.eecececececenccs Private employee benefit plans. Retirement..eeececececccee Temporary disability...ececececceas Supplemental unemployment benefitS...cceeecccccccescacscscncens Life insurance, death benefits, and accidental death and dismemberment.....cceeesecssccscscscsccccscssssscccnscce $h1, 72k 26,420 15,784 15,630 4,080 3,535 1,345 610 647 154 270 9 40 50 88 322 545 90 455 11,550 11,270 8,385 1,762 438 185 500 280 12,138 10,124 8,077 6,544 828 705 2,047 1,805 243 2,014 1,626 680 946 388 14,496 12,216 6,388 2,717 1,680 1,202 789 2,574 475 26 328 iz 2,779 2,280 785 1,495 570 475 450 $100,882 65,904 36,600 33,781 8,481 7,832 2,730 790 1,021 1,036 495 26 179 122 938 495 649 124 525 25,300 24,500 15,285 6,950 1,180 295 790 800 27,772 22,106 18,445 15,586 2,759 100 3,661 3,273 388 5,666 5,052 2,057 2,995 614 41,102 35,317 25,240 15,663 4,660 3,447 1,470 4,220 1,717 134 1,332 251 4,140 5,785 1,265 4,520 2,200 860 110 1,350 Source: U. S. Department of Health, Education, and Welfare; Social Security Administration: Social Security Bulletin, November 1962. 1/ Preliminary fiscal year estimates. 2/ Adjusted to eliminate duplication resulting from use of cash insurance benefits to purchase medical care and educational services. _3/ Payments made directly to suppliers of medical care in behalf of recipients; beginning November 1960 includes Medical Assistance for the Aged payments. _4/ Excludes medical benefits paid under public law in California and New York by private insured and self-insured plans; such benefits included in insurance benefits under private health expenditures. TDI means temporary disability insurance. _5/ Excludes school health expenditures which are included under "public health and medical services.” _G/ The estimated costs of providing medical services under many of the welfare programs are excluded from welfare and in- cluded under health. _7/ Total expenditures of private agencies from philanthropic contributions for such welfare services as institutional care, family counseling, recreation and day-care services, and emergency relief. 8h beneficiaries in current-payment status increased from 5.0 million to 18.1 million, and average monthly benefits increased--from $49 to $76 in the case of a retired worker. Total monthly OASDI benefits rose from a level of $205 i in December 1952 to a level approaching $1.2 billion in December 1962. Part of the growth in the social security system has resulted from suc- cessive extensions of coverage, particularly to the urban self-employed in 1954, the addition of disability insurance benefits beginning in 1956, and the provision of actuarially reduced insurance benefits at age 62--for women in 1956 and for men in 1961. Expenditures for OASDI are financed entirely from trust funds derived from the insurance contributions of covered workers and their employers; they are outside the general departmental budget. A number of other public programs also expanded significantly, but several grew from low expenditure levels. Vendor medical payments under ublic assistance, for which Federal matching in the form of grants was first authorized in the 1950 amendments of the Social Security Act, increased nearly seven-fold from $154 million to $1.0 billion. These payments include total payments under the Kerr-Mills medical assistance to the aged program amounting to $259 million in FY 1963 of which $13% million was from Federal funds and $125 million was from State and local funds. Medical research, only beginning to attract attention in 1953, increased from $88 million to $938 million, almost wholly through Federal action. Ex- penditures for maternal and child health and for crippled children's services rose sharply, primarily because of larger expenditures by State and local governments. Vocational rehabilitation programs expended, with expenditures for medical rehabilitation increasing by 189 percent and other expenditures rising five-fold. Private pensions increased three-fold from $0.6 billion to $2.2 billion, due both to an increase in the number of plans and to the maturing of those established earlier. Private pensioners and their wives now represent about 15 percent of the total sged population. Private pensions are largely sup- plementary to benefits under public programs. Four-fifths of all aged per- sons in mid-1962 were getting a regular income under OASDI, veterans, or other special public retirement program. Cash benefits under private employee benefit plans in the aggregate tripled in the ten years from $1.5 to $4.5 billion. Medical benefits under private insurance quadrupled, going from $1.8 to $7.0 billion. About three- fourths of private medical insurance is provided through employee benefit plans. Most of the money spent by private welfare agencies is used to provide services. Private philanthropic contributions used for such welfare services as institutional care, family counseling, recreation and day-care services, and emergency relief, amounting to $785 million in FY 1953, now approach $1.3 billion. 85 Public Expenditures for Health, Education, and Welfare Public expenditures include both Federal and State and local funds (Chart 2). Expenditures from public funds for health, education, and wel- fare accounted for about two-fifths of all governmental expenditures (Federal, State and local) in FY 1963 as compared with one-fourth in FY 1953. CHART 2 Public Expenditures for Health, Education, and Welfare, 1953-1963 Billions of Dollars 75 Billions of Dollars 75 60 Source of Funds in Constant (1963) Dollars 60 bd Federal State and Local 45 45 Social Insurance and Welfare 30 30 Education 15 15 Health 0 Health, Education, and Welfare Trends Public expenditures (in constent dollars) for health, education, and welfare increased 118 percent from $30.3 billion in 1953 to $65.9 billion in 1963 (Table 3). Federal expenditures over-all increased more rapidly (153 percent) than State and local expenditures (91 percent). Within the public sector there have been differential increases by category. Federal expenditures increased fer more rapidly than State and local expenditures in social insurance and welfare (181 as compared with 90 percent), somewhat more rapidly in health (95 vs. Tl percent), but less repidly in education (34 vs. 97 percent). Shifts during the decade 1953-1963 brought the Federal share to nearly one-half of all public expenditures for health, education, and welfare by 1963. By category, the Federal share now comprises three-fourths of public 86 social insurance and wel- di fare expenditures, but Public expenditures for health, education, and welfare by source of funds Billions of Doll. Perc re. less than one-half. of Denttiny sil 15 Som Mersin End health expenditures an a current | constant 1953 | 1963 1953-19632 2 TOTAL 26.4 30.3 65.9( 100 |100 118 substantially less than Federal maf 128 df ke ug | ass one-tenth of expenditures Sm) | 2 [poms |B HEALTH 1 4.7 8.5( 100 [100 81 for education (Table 4) . Federal 1.8 2.0 3.9] 43 | 46 95 State and Local| 2.3 2.7 L.6| 57 | su n EDUCATION 10.1 11.6 [22.1] 100 Public e enditures Federal 1.0 1.2 1.6 > 100 % £ a 1 Xp th State and Local| 9.1 10.4 [20.5] 90 | 93 97 or education more an kde oi vs SOCIAL INSURANCE AND : L. " doubled from $10.1 to tical ol lov HE RUBE $22.1 billion between State and Local| 3.9 by 8.k| 32 | 24 90 i ollars by the Social Security Administration on the basis of umption ex itures (1954100) developed by the National p penditus al e. The deflator for fiscal 1953 is 98.5 and for fiscal 1963 fiscal 1963) dollars. 1953 and 1963. State and ve local expenditures for = education increased from $9.1 billion to $20.5 billion; Federal expenditures increased only from $1.0 billion to $1.6 billion. In a period of expanding enrollments and of continuing heavy inter-state migration of families with school-age children, the share of educational expenditures borne by the Federal Government de- clined from 10 percent to 7 percent. The only sub-category in which the increase in Federal spending far outpaced that in State and local spending was in construction costs for higher education facilities; the absolute amount of Federal funds for this purpose was still only one-tenth of com- parable State and local spending in 1963. The FY 1963 expenditures for training under the area redevelopment and the manpower training and development programs ($23 million) are in- cluded with higher education other than veterans. These funds are appro- priated to the Department of Labor but transferred to the Department of Health, Education, end Welfare and administered by the Office of Education. The social insurance and welfare item for unemployment insurance and employment service includes the $59 million spent under these manpower programs in FY 1963 for special counseling and placement activities and for allowance payments. State expenditures for unemployment insurance and employment services combined increased somewhat more than Federal expendi- tures for these purposes (196 percent as compared with 158 percent) in spite of these new Federal programs. Federal Grants-in-Aid to State and Local Governments Intergovernmentel transfers in the form of grants-in-aid have provided an important vehicle by which the Federal Government encourages the States through financial assistance to undertake or expand key programs or activi- ties. Total Federal general expenditures increased from $72.5 billion in FY 1953 to $87.6 billion in FY 1962; grants to the States during the period increased from $2.8 billion (3.9 percent) to $7.7 billion (8.8 percent). Grants of $1.7 billion made by the Department of Health, Education, and Welfare to States, local communities, and public institutions accounted for 63 percent of total Federal grants-in-aid in FY 1953, but departmental grants of $3.2 billion accounted for only 42 percent of these expenditures in FY 1962. Grants comprised nine-tenths of total departmental expenditures 87 TABLE 4 Public expenditures for health, education, and welfare, by source of funds (In millions) Expendituresy Program or activity From Federul funds From State and local funds 195% 1963 195% 1963 Total public eXpenditures....eecescecreeecesaneanan [ER $11,146 $32,397 $15,283 $33,505 HEALTH--Total.eeseescasscrcess teccesttcetenctetttacerenanneennn 1,753 3,914 2,357 4,567 Health and medical SErviCeS.issssessinsvessnesssesnsines 1,541 3,556 2,004 4,276 General medical and hospital care--civilian programs.......ceeeeo... 68 136 1,277 2,59 Defense Department and Medicare pProgramS....eceseeceececcccscscccosnes 610 790 -——— -—— Veterans' hospital and medical care...... 647 1,021 -—- -—- Public assistance “eececerscstecttecorntestresqtetrecr rasan annnnnn 16 522 138 514 Workmen's compensation and TDI medical benefits J 6 8 264 487 Medical vocational rehabilitation..esscsscsceceess 4 16 4 10 Maternal and child health services. 27 48 24 131 School health...... --- -—— 50 122 Medical research...eeeessvsss .e 88 894 -— 44 Other public health ServiCeS.. esses cnseramnvessvamves samees soe p— 75 120 247 375 Nedical-facilities construction: cussssvessssisssncssissssnnseresnseees 212 359 333 290 Veterans Administration and Defense Department. 90 124 -—— ——— Other.cisasssssnessrreesssnererssevevrssvesrnne 122 235 333 290 EDUCATION=~TOLalssvunnenssessssvssosesvevessssassses vasaonsavasvasnss sae 1,041 1,605 9,083 20,500 CUrTent.vssssesnsnsssovvos snes iam 972 1,494 7,106 16,950 Elementary and secondary . 214 486 6,330 15,100 Higher education other than veterans. 52 909 776 1,850 Veterans... 705 100 -— —— Construction... seve vues 70 111 1,977 3,550 Elementary and secondary. 65 73 1,740 3,200 Higher education. vevessvnvrncavne serene suaenssnivassseses va vne sun 5 38 238 350 SOCIAL INSURANCE AND WELFARE--TotalT .euueeeereeeeneesnnenennneeennnnns 8,352 26,878 3,863 8,438 Social AnSUranCB.sw seen viv vrses vaEreEs EPEEET EERE § CEE CE ER 4,173 19,742 2.215 5,499 Old-age, survivors, and disability insurance.. . 2,17 15,663 -——— -—-- Railroad end public employee retirement,.... . 1,120 3,210 560 1,450 Unemployment insurance and employment Service...eceeescses . 289 747 913 2,700 Temporary disability insurance and workmen's compensation....eeseeces 47 121 742 1,349 Public assistance ‘excluding vendor payments) ...ceeccscececsececacsscns 1,344 2.318 1,229 1,902 Other velfar@.scecscscsnsves . 170 774 305 942 Vocational rehabilitationeescececescecenscescsccencrevsnnenns . 19 87 7 46 Institutional and other care, school lunch, and surplus food. . 143 666 185 665 Child welfare. Services. ssnecssecovesrvsnevssssmesvesves Corvereubes Lavy 8 20 113 231 Veterans' programs: Compensation and pensions and other welfare SETVICESeueranesnsenransesssasasesessessesssssssscsssssccnscnrense 2,665 4,044 114 95 Source: U. S. Department of Health, Education, and Welfare; Social Security Administration; Social Security Bulletin, November 1962. _1/ Preliminary fiscal year estimates. } 2/ Payments made directly to suppliers of medical care in behalf of recipients; beginning November 1960 includes Medical Assistance for the Aged Payments. Excludes medical benefits paid under public law in California and New York by private insured and self-insured plans. 3/ TDI means temporary disability insurance. _4/ Excludes school health expenditures which are included under ‘health and medical services.” 5/ The estimated costs of providing medical services under many of the welfare programs are excluded from welfare and included under health. from general revenues in 1953 and about three-fourths in 1962. Much of the remainder goes for direct research (mostly for health), patient-care activi- ties, and regulatory programs. 88 PART IIL CURRENT AND EMERGING ISSUES AND OPPORTUNITIES Health 89 a iad AIR POLLUTION Roy Head and Luther W. Stringham Air pollution is the presence in the air around us of substances put there by the activities of man, in concentrations sufficient to interfere directly or indirectly with his comfort, safety, or health, or with the full use and enjoyment of his property. Air Pollution No Longer Primarily a Smoke Problem Until about 30 years ago, concern with air pollution was limited to smoke or other pollutants that could be seen or smelled. These pollu- tants often were tolerated because smoke in a community meant busy fac- tories, more business, and more jobs. Gradually the public began to de- mend curbs against excessive smoke, and a number of American cities, led by St. Louis and Pittsburgh, enacted control legislation. Since then, advances in technology--new fuels, better combustion, improved dust collectors--have further reduced the level of settleable solids in our cities. But this same technology--advancing ever faster, especially since World War II--has discharged scores of new pollutants, many of them invisible, into the air we all must breathe, and has multi- plied the volume of many older pollutants. Today's Air Pollutants Are Numerous and Varied Today's pollutants are such waste products as the dusts, smoke; fumes, and liquid droplets that hide the sun, delay aircraft operations, and soil our buildings and our clothing. They are gaseous discharges like sulfur dioxide, carbon monoxide, oxides of nitrogen, and hydrogen sulfide. They are metallic fumes and dusts from lead, vanadium, iron, and their compounds. They are fluorine and phosphorus compounds which have proved harmful to plants and livestock. Finally, they are contami- nants created in the air, under the influence of sunlight, by the inter- action of some of these substances. For example, invisible clouds of hydrocarbons and oxides of nitrogen are "triggered" by sunlight to form photochemical smog of the typical Los Angeles variety. The Sources of Air Pollutants are Equally Varied Air pollutants come from the exhaust pipes and the crankcases of our automobiles and trucks, from the chimneys of our homes, and from trash and leaf: fires in our backyards. They come from municipally owned Mr. Head is the Assistant Chief of the Information and Education Office, Division of Air Pollution, Public Health Service; Mr. Stringham is the Director, Office of Program Analysis, Office of the Assistant Secretary (for Legislation), U. S. Department of Health, Education, and Welfare. See section on "Air Pollution," in the Report of the Committee on Environ- mental Health Problems (PHS Pub. No. 908, 1962) for consideration of long- range objectives, with particular reference to manpower, research, and relationships with other Federal agencies. A basic source is Proceedings: National Conference on Air Pollution, 1958 (PHS Pub. No. 654, 1959). Health, Education, and Welfare Indicators, May 1962 91 power plants and burning municipal dumps, from apartment house incin- erators and commercial enterprises in every city and town. They come from oil refineries and storage tanks, from trains, airplanes, and vessels. They come from factories, of almost every kind. All these are the more familiar sources of air pollution. U. S. Growth Factors Will Multiply These Sources Present-day forces in this country which threaten to worsen air pollution in the coming years include continuing increases in our popu- lation, urbanization, transportation, and industrialization, and in scientific research, which is creating new processes and products. (See charts.) Each of these is increasing rapidly, the rate of increase is accelerating, and the growth of each factor stimulates the growth of the others. For example, the impact of population growth is compounded by in- creasing urbanization. From 1940 to 1950, "Standard Metropolitan Areas" absorbed 81 percent of our total population growth and by 1955 were ab- sorbing 97 percent. By 1970 it has been estimated that three out of four people will be living in only 10 percent of the land area of the United States. Thus, an increasing portion of the waste products discharged to the atmosphere will be released into relatively small segments of the air mass. Atmospheric Conditions Affect the Degree of Pollution The degree of air pollution thus is related to the variety and quantity of materials discharged into the atmosphere. It is also a prod- uet of atmospheric conditions which prevent adequate alr circulation. Normally, air currents disperse and dilute the pollutants. Air near the ground is warm and tends to rise through the cooler upper layers of the atmosphere. If there is an inversion in temperature, however, the air near the ground is cooler than the upper layers of the atmosphere, and the abnormal layer of warm air acts as a 1id, effectively boxing in the air below. The Air Pollution Problem is Widespread in the United States Twenty years ago, no one in Los Angeles had ever complained of smog-caused eye irritation, and that city did not institute its first control measure until 1947. A dozen years ago, San Francisco was paying little attention to its air pollution problem; today the San Francisco Bay Area has one of the most active air pollution control agencies in the nation. In 1953, New York City had its first detected smog "episode," to which some 200 deaths are attributed. Washington, D. C., probably the least industrialized U. S. city of its size, had its first recorded in- stance of Los Angeles-type smog in June 1960; there have since been several more. Also in 1960, Boston had its famous "black rain," a literal downpour of smoke, soot, or oil, or a mixture of all three. Gross National Product uv. S. GROWTH FACTORS More People and More of Them WILL MULTIPLY AIR POLLUTION SOURCES r More Emissions from More Automobiles 220 soil [ Living in Large Urban Centers 2004 & 100 Z 180 : Total Population Zz 160 80} & » . 7 7 5 / 2 ; S140 . = RB = 7 3 & = 7 a & ~~ . ov fo Sy § / £60 ; 0 . z , 5 / 3 2 3120p . > s FI i’ 3 ih Urban Population 7 3 7 of 7 »” 100 7 40 F RB 7 rd 7 * 7s “a 7 at 80 7 7 .® —- = 20 60 "w 0 1 1 1 1 0 1 1 1 J 1930 1940 1950 1960 1970 1930 1940 1950 1960 1970 600 More Goods and Services 15 [ More Research and Development for More People Result in More Varied Pollutants 1 I 1 500 F / } / 1 , / / / / __aoof 7 — lof 1 § JS 3 J a 8 | So / - x / ° 1 2 s I 2 3000 z I 2 J = 1 - o I 2 2 / $ % / Qo & / < / sh 1 1 | / / Fd 100 p ’, 7 7 7 td td 7 td — 0 2 L ) 0 lew sem mb ' 1 J 1930 1940 . 1950 1960 1930 1940 1950 1960 Approximately 90 percent of our urban population lives in locali- ties which have air pollution problems. Large city or small, industri- alized or not, few cities are immune. Many of these localities are large urban complexes which spread across State boundaries. (See map.) It is estimated that all 212 communities (Standard Metropolitan Areas) with a population greater than 50,000 have air pollution problems; approximately 40 percent of the communities in the 2,500-50,000 population range have problems. In total, about 6,000 U. S. communities have air pollution problems of varying degrees. Farmers, too, are affected. In Florida, fluorides from phosphate processing plants accumulate in and on vegetation. These fluorides, ingested by cattle, can cause fluorosis, which may seriously affect milk production. In many other States, including California, Idaho, Montana, New Jersey, Oregon, Tennessee, Utah, and Washington, damage from air pollution has been detected and identified, with claims of damage ranging from a slight reduction in crop yields to the loss of the entire farm enterprise. Economic Losses Attributed to Air Pollution Current national estimates of economic damage caused by air pollu- tion range from $4 billion to $11 billion annually. They include injury to livestock and vegetation, corrosion and soiling of structures and materials, interference with visibility, reduction of property values, ete. Adverse Health Effects Attributed to Air Pollution Acute episodes have demonstrated that heavy concentrations of air pollutants can produce acute illness and sudden death. Of greater sig- nificance, however, is the long-term exposure of community populations to lower concentrations of air pollutants, which may result in gradual deterioration of health, chronic disease, and premature death. An impressive body of circumstantial evidence 1s now accumulating which links air pollution with increased mortality from cardio-respiratory causes, increased susceptibility to respiratory disease, and interference with normal respiratory function. Among the diseases so linked to air pollution are asthma, chronic bronchitis, emphyszma, and lung cancer. The last two especially have been increasing rapidly in this country. Current Efforts to Deal With the Air Pollution Problem Research, conducted or sponsored by the Public Health Service, on the nature, sources, scope, and effects of air pollutants and on instru- mentation and other measures for their better control. Technical assistance to States and communities by the Public Health Service. oL EUGeye RENg G6 8% estes su on A DiEGy AN 8) ONTARNARD THERE ARE AIR POLLUTION PROBLEMS IN THE 212 AREAS WITH 50,000 OR MORE RESIDENTS | FALLs we. * FARGO- MOORHEAD GREEN BAY MILWAUKEE MADISON DUBUQUE WATERLOO ceoar rarios [ff Woes MONS CHICAGO DEN MOLINE HAMPAY FROCK ISLAND vs I CHAMPAICH UNCOLN B TEV8 0 | =e SPRINGFIELD INDIAN rsh DAYTON ~ € HAM RRE HAUT IDOL ps CINCINNA 0 SIOUX CITY KENOSHA ROCKFORD dl 8 z OMAHA Saxe EROVO_oRgy ST JOSEPH Kansas cy ke ¥ST Lous DECATUR of c lg wy TOPEKA Jr EVANSVILLE WICHITA ll SPRINGFIELD AMARILLO ASHEVILLE INO. Ry VERSIE. IY Lsuoveroue WICHITA FALLS LuBOCK ABILENE ooesss MIO “Bs ANGELO ® co EL PASO TON- BEAUMONT SERKESTRY PORT ARTHUR SAN woolly TAMPA- ST PET 7 el a /HONOLULU / 7 / ’ / / / eo / i 7 oy, / ORPUS CHRIST! * Stars indicate interstate areas Area Definitions by Federal Committee on Standard Metropolitan Statistical Areas under the direction of U.S. Bureau of the Budget ZRQWNSVALLE- HARLINGEN- ) SAN BEN CEN STANDARD METROPOLITAN STATISTICAL AREAS: 1960 DEPARTMENT OF COMMERCE WINSTON NASHVILLE [ wos ERSBURG LENT Tow SBA! NESTON phot CHARLESTON {at JACKSONVILLE ORLANDO fen 330 Hi ant So er SHS fr TON ake ’ Ri NENAVEN ROGER WORN nx oN Naue ORG ron ences? on ssc ¥ NEWARK art TATE 3 wine Wh ELPHIA * ° WEST PALM BEACH A \ FORT | AUDERDALE-HOLLYWO? MIAMI ® © - —t mn @ BUREAU OF THE CENSUS Technical training for air pollution personnel at Federal and local governmental levels and in industry, at the Public Health Service's Robert A. Taft Sanitary Engineering Center in Cincinnati, and in several universities. Industry is reported to be spending as much as $300 million annually for air pollution control measures.* State and local control programs, which vary widely in scope and effectiveness. Some of the principal research activities and the present status of State and local control programs are summarized below. Illustrative Research Activities¥¥ Research projects conducted or sponsored by the Public Health Ser- vice are partly engineering and partly medical, and many of them involve interdisciplinary collaboration. The most widespread project is the National Air Sampling Network, which has at least one urban and one nonurban air sampling station in every State. (See map.) The Network provides continuing information about what is in the air and in what concentrations, and helps cooper- ating State and local agencies to deal with their own specific problems. On June 30, 1962, the Surgeon General will report on the results of a special two-year study of the effects of automotive exhaust on health. This study is being conducted at the Sanitary Engineering Center. The study includes human eye irritation, vegetation damage, and effects on animals of short-term and chronic exposures. Also being examined are the effects of variations in the chemical composition of the exhaust. Other research projects include studies of the nature, sources, and interactions in the air of pollutants; of meteorological aspects; and of improved instrumentation and other control measures. Other Research Projects Concentrate on Health Effects of Air Pollution The circumstantial evidence which links air pollution to certain cardio-respiratory diseases comes from three types of investigations: (1) statistical studies of past morbidity and mortality, as correlated with geographic location and other factors associated with air pollution; (2) ongoing epidemiological studies of morbidity and respiratory function as related to variations in air pollution; and (3) laboratory studies of responses by animals--and by humans in some cases--to exposure to various pollutants, either singly or in combination. *0n December 6, 1961, the automotive industry agreed to install blowby devices on all new cars, starting with 1963 models. *¥The Public Health Service programs are authorized by P.L. 84-159 (1955) and P.L. 86-493 (1960). 96 EY Gy 213-Station ) 1 \ NATIONAL AIR SAMPLING NETWORK - 1962 Hy NJ U.S. Public Health Service ; A®HAWAL M——. Jr yy LEGEND: @® EVERY YEAR AIR SAMPLING STATIONS O BIENNIAL AIR SAMPLING STATIONS \ 2 A NONURBAN AIR SAMPLING STATIONS = 3 [] PRECIPITATION GOLLEGTING STATIONS \ N PUERTO RICO 7d A S Robert A. Taft Sanitary Ao A ey Engineering Center, Cincinnati, Ohio / A PORT WORONZOFF, ALASKA J @ ANCHORAGE, ALASKA = The following results are typical of recent findings from these studies: + Death rates from cardiorespiratory causes are greater in urban than in rural areas and generally increase with city size. Variations in morbidity within cities correlate with variations in air pollution. + The Medical Director of a large eastern industrial firm recently reported a similar correlation between total atmospheric sulfates and employee absenteeism due to respiratory illness among women workers. a7 - Studies in Donora, Nashville, New Orleans, and elsewhere point to the impact of air pollutants upon elderly persons with cardio- pulmonary conditions in rendering them more susceptible to pulmonary irritation and respiratory embarrassment. * An investigator at the University of Southern California has reported the production of a typical human form of lung cancer, by inhalation alone, in laboratory animals exposed to ozonized gasoline sub- sequent to their recovery from infection with influenza virus. Although hundreds of other research projects are under way, and much more research is needed, a great deal has already been learned about air pollution in a relatively short time. We already know how to con- trol or prevent the majority of air pollutant emissions at costs to the community which would generally be less than the economic damages they produce. Nationwide Needs Vs. Current Status of Control Activities Public Law 84-159, (passed in 1955) specifically reserved respon- sibility for the control of air pollution to States and communities. Accordingly, the wide application of technical procedures now available for air pollution control is dependent upon the development and operation of community programs on State and local government levels. Community control programs, however, are still far from adequate. On the State level, during the past decade, there has been some improvement in the status of air pollution legislation and in the develop- ment of comprehensive programs dealing with problems in this area. Some 15 States now have enactments which authorize specific programs, whereas no State had such authorization in 1950. According to a recent survey, there are only 106 local control pro- grams which have full-time staffs. These programs serve 342 local politi- cal jurisdictions, which contain about 45 percent of the national urban population. Only 28 of these control programs have five or more full-time employees. The total expenditure by local governments for air pollution control presently is about $8 million annually, more than half of which is expended in the State of California alone. The median annual expenditure for air pollution control is about 10 cents per capita. That figure compares with as much as $65 per capita for air pollution's economic costs alone. Thus, the most immediate need is to apply--far more widely than it is being applied at present--what is already known about air pollution control. 98 WATER RESOURCES AND POLLUTION CONTROL Helen E. Martz and Earl E. Huyck: Clean water is essential to our industrial technology, agriculture, the conservation of natural resources, our health and welfare, and even life itself. Polluted water can lead to debilitating illness, premature death, and reduced economic productivity. The Nation's limited and relatively fixed supply of fresh water is becoming increasingly polluted. How to conserve and make most effective use of available water is emerging as a serious natural resource problem. Demand is Overtaking Supply The Nation's water supply is largely determined by its precipitation-- rain and snow. An average of 30 inches falls on the continental United States a year (Map 1). But only about 2 inches is available to man on a dependable year-round basis; 22 inches return to the atmosphere through transpiration and evaporation, and most of the remainder runs back to the ocean and is gone before it can be used. The ocean itself offers considerable potential as a source of usable water, and, as costs are reduced, saline water conversion will be increasingly utilized along our southern California and western Gulf Coast areas. For the foreseeable future, however, there are economic limits to the degree that water can be de-salted and moved any substantial distances inland for irrigating fields and for supplying urban populations. Owing to the costs of conversion and movement of water from the sea, the water now in the country's rivers, lakes, and streams, plus the collected precipitation, constitutes the total of the Nation's dependable fresh water supply. Dr. Martz is a Social Welfare Adviser in the Bureau of Family Services, Welfare Administration; and Dr. Huyck is a Program Analysis Officer in the Office of the Assistant Secretary (for Legislation), U.S. Department of Health, Education, and Welfare. Based on data provided by: (1) Public Health Service, Division of Water Supply and Pollution Control--Evaluation of Water Supply and Pollution Control Needs, November 1960; "Proceedings of the National Conference on Water Pollution," December 1960; Clean Water--A Chart Book on America's Water Needs, 1900-1980, December 1960; Report of the Committee on Environmental Health Problems (PHS Pub. No. 908, 1962); and Pollution-Caused Fish Kills in 1961 (PHS Pub. No. 847-1961); and (2) U. S. Department of the Interior, Office of the Secretary, Office of Saline Water, and the Geological Survey--Resources for Tomorrow: 1961 Annual Report. See also: Wilbur J. Cohen and Jerome N. Sonosky, "Federal Water Pollution Control Act Amendments of 1961," Public Health Reports, February 1962. U. S. Senate, Select Committee on National Water Resources; Water Resource Activities in the United States; 1960 Committee prints-- No. 3, "National Water Resources and Problems;" No. 30, pertaining to re- use of water; No. 24, water quality management; No. 7, municipal use; No. 8, industries; and No. 13, agriculture. "Water:CW Special Report," Chemical Week, October 7, 1961. - Health, Education, and Welfare Indicators, October 1962 22 PRECIPITATION PATTERNS INCHES : UNDER 20 0700 @ 40 TO 60 & OVER 60 ® ANNUAL AVERAGE Through conservation measures, the 315 billion gallons a day avail- able (1960) is expected to be developed to about 515 billion gallons by 1980 (Chart 1). But the need for water is expected to nearly double present use by 1980, and another doubling of need is predicted by the year 2000. Yet, foreseeably, the most that can ever be hoped for is between 600 and 650 billion gallons of water a day. Use Rate of Fresh Water Vs. Estimated Dependable Supply (Billions of Gallons Per Day) 1900 1920 1940 1950 1960 1970 1980 Rate of Use... .. 40.2 91.6 136.4 202.7 3229 411.2 9597.1 Water re-use will become Dependable a ————————— Supply. 950 125.0 2450 270.0 315.0 3950 515.0 increasingly necessary as our water demands increase with con- tinued economic and population growth. Re-use, however, depends on our ability to prevent deterioration of the supply to such an extent that re-use becomes impracticable. The control of water quality is the key to the amount of re-use that can be achieved and therefore to the amount of water we shall have available for future needs. The control of water quality requires the effective control or treatment of pollution wastes at thelr source, supported by the regula- tion of receiving streams to the degree necessary to assimilate treated waste effluent discharged to them. In some arid areas of the country heavy water demands already exceed the available supply, and multiple re-use is the only means of meeting the demands. Present waste treatment technology is not sufficiently advanced for the complete treatment of waste water so as to make possible indefinite re-use of water. These waste waters, however, contain only a fraction of the dissolved solids present in most saline waters. The waste waters are immediately available and need not be transported long distances or pumped 100 from deep underground sources. It is conceivable that a supply of water can be used over and over, if means can be found to remove the small but important amounts of dissolved materials remaining after currently available treatment. Advanced waste treatment research is actively being undertaken at the present time to develop the necessary technology. Potential methods for treating resistant wastes feature the use of physical-chemical separa- tion principles that have already been used to some extent in sanitary engineering. Chart 1 550 500 “01 DEMAND OVERTAKES SUPPLY 400 VS. DEMAND IEENENES 350 BILLIONS OF GALLONS PER DAY — SUPPLY Unprecedented Population and Economic Growth Requires More Water Increasing population in the United States, which more than doubled since 1900 and is expected to nearly double again by the year 2000, requires more clean water for drinking and for other home uses. With higher levels of living, the bathrooms, kitchens and home laundries available to most people today consume far more water than a generation ago. Industrial growth, essential to a growing population and an expanding economy, requires an increasing amount of water to produce the things more people need to eat, wear, and use. Industry increased its output of goods by TOO percent since 1900 and is expected to more than double this volume 101 by 1980. Industry, the largest user of water, will need twice as much by 1980. With new Past and Future Use of Fresh Water (Billions of Gallons Per Day) : 1900 1920 1940 1950) 1960 1970 1980 technologies and automation, Municipal . . . . .. 30 60 10.1 14.1 22.0 27.0 37.2 Industrial... .. 15.0 27.2 52.0 84.0 159.9 218.3 394.2 one can only speculate on the Agricultural |... 222 58.4 741 1046 141.0 1659 165.7 increased volume of production Total... ... 402 91.6 1364 202.7 3229 4112 597.1 by the year 2000 and its in- creased need for water, for many of the newer technologies are those which use the greatest amount of water. To provide more food for more people, water is increasingly used for irrigation. Water is essential for fish and aquatic life, and wildlife. More people, higher income, more leisure time, and better transpor- tation also have kindled a new national interest in recreation, with increasing use of clean water for sports, fishing, boating, and hunting. Recreation is a principal source of income in some States, and a major source in others. According to the National Recreation Survey conducted by the Outdoor Recreation Resources Review Commission, Ll percent of the population prefer water-based recreation activities over any others. This trend is likely to continue as more young people acquire an interest in water sports, new reservoirs are constructed, the boating industry wins new converts, and relatively new forms of water-based recreation, such as skin diving and water skiing, become increasingly popular. The trend will be accelerated if pollution control programs are successful in cleaning up streams, lakes, and seashore areas that are presently off limits for recreation, or are now so unattractive as to preclude many activities. The changing character of America is reflected in the changing demands for water among municipalities, industry, and agriculture (Chart 2). Chart 2 LLL SR GA LATE EL THERE Sh MUNICIPAL 37 IRRIGATION 141 od a : IRRIGATION 166 LL] TR 1960 i] 0 LIVI 7] BIL/GAL 102 Many People and Industries Are Not Near an Adequate Water Supply Nature distributes water unevenly, seasonally and geographically (see Map 1). For example, about two-thirds of the rainfall is on the Eastern and one-third, on the Western half of the United States; evapora- tion losses are highest in the Southwest and lowest in the Northwest. Water, therefore, has to be stored and transported from areas of surplus to areas of shortage. The accelerating westward migration of people into water-short areas of the West and Far West imposes additional burdens on existing supplies of fresh water. The spring runoff from winter snow is closely watched and channeled. There are numerous claimants for the division of the existing water supply--State and local governments, irrigation farmers and industrial firms. The courts are deeply involved with the problem of fair distribution of water from one water basin to another, the 10-yéar litigation over the waters of the Colorado River being a case in point. Voters are asked to pass upon bond issues for the necessary capital investment for water facil- ities. California voters in 1960, for example, approved the issuance of $1.75 billion in general obligation bonds to undertake a water conservation and distribution program to be completed by about 1982. Water from the Feather River in northern California will then flow THO miles through rivers, reservoirs, and tunnels as far as San Diego County to take water to the farm lands and to the people in the cities. An increasing proportion of the population now live in metropolitan areas--70 percent in contrast to 15 percent in 1900--and the number of metropolitan areas is increasing. Water must be transported to those cities not near an adequate supply of fresh water. Growth of cities will multiply the transportation problem. Many water-using industries which locate in water-short regions because of other advantages aggravate water supply problems. Pollution is Increasingly Spoiling the Nation's Usable Water Supply All wastes that are not burned, buried or released to the atmosphere go back into the basic fresh water supply. The increasing discharge of pollutants is directly related to developments contributing to the increased demand for water. An expanding population increases the volume of waste, and the crowding of people into urban centers intensifies the problems of waste disposal. Changing land practices involving the increased application of commercial fertilizers, and development and widespread use of a vast array of new herbicides and insecticides contribute to pollution problems through land drainage. Increased production of goods increases the amount of common organic and inorganic industrial wastes, and new technologies produce new wastes that defy current ability to treat or control them, and in some instances, even to detect their presence in water. Substances which are harmless in themselves react chemically with other substances to produce noxious odors and tastes, exotic and undesirable compounds. 103 Detergents and other synthetic wastes, not affected by present-day treatment processes, are reaching the consumer in increasing amounts. Syn- thetic detergents were of minor importance until the late 1940's. By 1958, however, the consumption of synthetic detergents in the United States amounted to 3.8 billion pounds--three times the consumption of soap. Almost the entire annual production of synthetic detergents is eventually discharged to surface or ground water. Unlike soap, which is readily decomposed, several of the compounds in synthetic detergents resist chemical and bio- logical decomposition and partially survive sewage treatment, river self- purification processes, and ground water travel, and, even after subsequent processing in water treatment plants, appear in varying reduced amounts in drinking water. There is now nearly six times as much pollution in our rivers, streams and lakes as 60 years ago, and the amount is still increasing. Tor the fore- seeable future, the Nation's streams must continue to function as the final place of disposal for its liquid wastes (Chart 3). Some 23 States border on the ocean, and their estuarine and coastal waters have been subject to serious and increasing pollution for many years. Sea water intrusion is caused by excessive pumping of fresh ground water, which lowers the water table, allowing salt water to flow into the ground water aquifers. Already a widespread problem, it is now of particular sig- nificance in California, Maryland, New Jersey, Texas, and New York. Oil fields brine disposal practices also are causing salt pollution of ground waters in the Midwest and Southwest. Sewage and industrial waste oxidation ponds, and waste storage lagoons are sometimes additional agents of ground water pollution. Chart 3 8 INCREASING WASTES IN OUR WATER, 1900-1360 POPULATION EQUIVALENTS, IN MILLIONS & MUNICIPAL WASTE INDUSTRIAL WASTE 1950 1940 10h The Backlog of Sewage Treatment Needs is Great To eliminate the backlog of needed municipal sewage treatment works, to replace plants that will become obsolete, and to provide for the continuing population growth in our urban areas will require an annual average expendi- ture of $600 million for the next decade, according to Public Health Service estimates. The Conference of State Sanitary Engineers in May 1962 disclosed that 5,290 communities serving 43 million people, or nearly one-fourth of the Nation's total population, require new sewage treatment plants, plant enlarge- ments, or additional and more effective treatment facilities. The estimated cost of eliminating this backlog including ancillary works is $2.1 billion (Table 1). Needed sewage treatment works for industry are of the same order of cost, and the need for new treatment processes applies to industrial as well as municipal wastes. As shown in Table 2, every State has communities with unmet sewerage needs. Of the 50 States and four other political divisions reporting treat- ment needs, 26 States showed improvement in municipal treatment facilities, four listed no change, and 24 reported greater unmet needs in 1962 than in 1961, when a similar inventory was conducted. The aggregate population of communities with less than 25,000 residents needing municipal sewage treatment works accounts for only 32 percent of the total population of places in all size categories but comprises 62 percent of the total estimated cost of such works. Table 1 Needed Municipal Sewage Treatment Works January 1, 1962 Number of Projects Total projects Population Addi- Population Estimated cost size group Total New Expan-| tional served Millions| Per- plants sion |treat- | Number | Pex- of gent ment | (000's)| cent| dollars Under 500 1,084 [1,022 13 Lg 334 .8 56.6 2.7 500 - 1,000 1,213 1,085 40 88 861 2.0 122.9 5.8 1,000-5,000 2,120 | 1,626 302 192 4,391 | 10.1 556.4 26.1 5,000-10,000 416 262 117 37 2,850 6.6 268.7 12.6 10, 000-25, 000 273 157 £7 29 5,191 | 12.0 318.3 14.9 25,000-50,000 76 37 33 6 4,035 We 3 14h .5 6.8 50,000-100,000 56 35 15 3 3,630 8.4 174.8 2.2 Over 100,000 52 20 23 9 22,029 { 50.8 488.6 22.9 Total 5,290 | 4,244 633 413 43,321 |100.0| 2,130.7 | 100.0 Source: See footnote to Table 2. 105 Continuing and Emerging Water Problems Areas in which water problems are particularly severe are shown in the shaded portions of Map 2 prepared by the U. S. Geological Survey. Problems of rainfall variability and of floods are age-old. Map 2 INTL DISTRIBUTION ILL CHEMICAL AND | ETT "POLLUTION ARTE VARIABILITY Construction of additional water storage facilities--ranging from the farm pond to the city reservoir and the multipurpose dam--can improve the efficiency of usage of the existing supply of fresh water. Pipelines and irrigation ditches can partially overcome the uneven distribution of existing supplies. Saline conversion of sea water and inland brackish water can expand the existing supply of water. Substantial amounts of water can be re-used with little loss. Population growth and rising industrial demands nonetheless will necessitate the use of a combination of methods and a con- tinuing search for new methods to use the existing supply of water and to develop new sources of water. But effective water usage involves more than methods. It also involves a willingness on the part of governmental units-- Federal, State, and local--to work together. 106 Federal Legislation and Action in Water Pollution Control and Desalination Because. of the national scope and enormous complexity of the problems of water supply and pollution control, the States, lacking adequate resources to do the required job in pollution control, have been looking increasingly to the Federal Government for financial assistance and technical services. Within the Federal government the Army Corps of Engineers, the Bureau of Reclamation (Department of the Interior), the Soil Conservation Service (Department of Agriculture), the Tennessee Valley Authority, and the Federal Power Commission regulate the quantity of water through flood control and other means. The primary objective of Public Health Service programs is the development of comprehensive programs for the maintenance and improve- ment of water guality, through preventive as well as remedial measures. The Water Pollution Control Act of 1948 (P.L. 80-845), a first Federal step in combating water pollution, formed the basis for the Water Pollution Control Act of 1956 (P.L. 84-660), which provided a broad basis for a national Federal-State cooperative program, including (a) grants to con- struct municipal waste treatment facilities, (b) grants to improve and strengthen State and interstate programs, (c) more workable Federal enforce- ment, and (d) more effective research. The 1961 amendments to the Water Pollution Control Act (P.L, 87-88 established a Federal-State-local attack with greater capability of meeting water supply and pollution control problems. These amendments broadened and strengthened the Federal government's enforcement powers; provided the basis for a greatly stepped-up program of waste treatment works construc- tion; authorized increased Federal support of State and interstate pollu- tion control programs; provided for an intensified program of research looking toward more effective methods of pollution control, with special emphasis on regional variations; and established in law the principle of water quality control as a criterion in planning and building Federal reservoirs. Comprehensive planning for water quality management--the most important activity specified under the Act--requires an inventory of the sources and effects of water pollution. Agreements on desired water use and quality are then developed. Pollution control measures are outlined to achieve the desired objectives, and a timetable is established Tor their accomplishment. Regional programs involve broad engineering, hydro- logic, economic, legal and related studies together with field investiga- tlons--all carefully integrated with other water resource projects and proposals and sufficiently flexible to permit adjustments to changing economic growth patterns. Under the provisions of P.L. 82-448 of 1952 and P.L. 85-883 of 1958, the Secretary of the Interior established the Office of Saline Water to develop conversion processes for sea. water or other saline waters and to construct and operate five saline water conversion plants to demonstrate the engineering and economic potentials of conversion processes. In 1961 107 P.L. 87-295 authorized $75 million for an expanded and accelerated program of basic and applied research through fiscal year 1967. The Department of the Interior is responsible for developing the necessary technology for the economical conversion of saline waters. Three of the five demonstration plants authorized by Congress are already operative. These include one at Freeport, Texas, the first sea water conversion plant to regularly supply the needs of a U.S. municipality. This plant and the one at San Diego, California, of one million gallons per day capacity each, feature distillation processes. The Webster, South Dakota plant on the Northern Great Plains converts brackish water. The remaining two plants at Wrightsville Beach, North Carolina and Roswell, New Mexico are well under way and will be tested before the end of 1962. Based on Office of Saline Water cost estimates, the three plants now under construction will produce fresh water at approximately $1.00 to $1.25 per thousand.gallons. This price level is comparable to 5 to 10 cents per thousand gallons for treatment only for water from fresh water sources. Source development and distribution costs, averaging 25 to 30 cents per thousand gallons, must be added in both cases. While we must continue to supplement our gross water supply by desalination of marine and brackish waters, by weather control, by evapo- ration reduction, and by other means yet to be developed, we must still look to used waters as the major source of water supply in the foreseeable future. Measurement of Water Quality and Pollution Control Realizing the need for continuing measures of water quality manage- ment through State, interstate, and other agencies, the U.S. Public Health Service in 1957 established the National Water Quality Network. By mid-1962 more than one-third (113) of the 300 sampling stations planned were opera- tive on the Nation's waters (Map 3). Content analyses are made to determine the nature and extent of organisms, organic and inorganic chemicals, trace elements, and radioactivity in water samples. The resulting data will be useful in determining long-range water quality trends, in selecting sites for water uses and in developing eomprehensive water resource programs. A second rough indicator of water pollution initiated by the Public Health Service's Division of Water Supply and Pollution Control has been the "eish-kill" count based on data supplied by State conservation and fish and game agencies. From the beginning of the project in June 1960 through the end of 1961 a minimum of 21 million fish were reported killed in the rivers, streams, and lakes of 45 States. Their source of oxygen had been cut off by industrial wastes, mining operations, agricultural poisons, domestic sewage, and other imputed causes. 108 The Public Health Service has undertaken a Pesticide Control Project to determine the presence of herbicides and insecticides in surface streams and in ground waters and eventually to assay the effects of exposure of humans and aquatic life to long-term, low-level concentrations of these materials through the "food-chain mechanism." Investigations are currently underway in South Carolina, Florida, Alabama, and Louisiana. The Federal government has completed an extensive inventory of its own facilities as the basis for developing an action program for control of water pollution on its premises. The Public Health Service in 1962 issued a series of 58 volumes, by State and by Federal government depart- ment, entitled Waste Water Disposal Practices at Federal Installations. Map 3 PUBLIC HEALTH SERVICE National Water Quality Network SAMPLING STATIONS June 30, 1962 - 113 Stations J A Federal-State Action on Water Resources and Pollution Control In cooperation with other Federal agencies, State and interstate water pollution control agencies, and with the municipalities and industries involved, comprehensive water pollution control programs are now being developed for six major river basins. These include: the Arkansas-Red, the Colorado and the Columbia Basins, the Great Lakes-Illinois River 109 Waterway Basins (which will require seven years and some $12 million to complete), the Delaware River Basin, and the Chesapeake Bay and its tributaries. Under directive from the President, within the next ten years such planning will be under way or completed for all the river basins of the United States. After years of negotiation, the Federal government and the legisla- tures of Delaware, New Jersey, New York, and Pennsylvania recently approved a five-way compact for the Delaware River Basin Program. The Federal government is a one-fifth partner but has veto power over projects involving Federal spending. The Delaware Commission will base its construction plans on a study made by the Army Corps of Engineers covering the 50-year period to 2010. The Corps has recommended authorization of eight major projects at an early date. Eleven of the 19 major dams and all 39 of the minor projects are expected to be completed by the year 2010. Provision will also be made for flood control, navigation, and recreation. The Department of Health, Education, and Welfare in December 1961 agreed to join with the States of Washington and Michigan in two separate intrastate water pollution enforcement actions applying to United States waters and sources of pollution only. The two actions were the first to be taken under new provisions of the Federal Water Pollution Control Act, which permit the Secretary to invoke Federal enforcement procedures in intrastate waters when invited to do so by the State Governor. The procedure calls for a conference, which is followed, if necessary, by public hearings and action in the Federal courts. Action by Industry in Controlling Water Pollution Industry also is becoming more conscious of its responsibilities for controlling water pollution. While some industrial firms are responding to State anti-pollution requirements, others are acting voluntarily. Recycling the same water through the manufacturing process rather than discharging it into streams after one use 1s making pollution control more appealing to companies by actually cutting their water costs, particularly through the reduction of the volume of wastes to be treated. In summary, age-old and increasing water problems will not be solved overnight. Several Federal government agencies are adapting existing tech- niques and developing new technology to provide for the needed quantities of water of adequate quality from fresh water, re-used water, and water converted from the sea or from brackish sources. The Federal government and the States have begun to work together in the search for solutions to regional water problems. Industry is also becoming aware of the desirability of providing for pollution control for economic as well as public health reasons. 110 Table 2 NEEDED MUNICIPAL SEWAGE TREATMENT WORKS (Population in thousands ; estimated cost in millions of dollars) State or Number of Projects BLYET aieh New Additional Population Estimated Plants Expansion Treatment Served Cos TOTAL... vvevnn... b, 2! 633 3 43,321 2,130.7 UNITED STATES 4,221 633 k11 43,213 2,118.0 (50 States and D.C.) ALaBOIR oo 000 vw sn 76 9 2 364 29.1 BLagKa. sous vivy nny 25 * * 101 12.3, ALLIONG: + v5 wvwvnivin 23 3 k 185 22.6 ATKANSAS. .. vivian 85 10 18 370 19.9 CALICOMI Bs nnmnnic 196 27 1h 4,111 188.5 COLOBEAD: iswih mis mcninen 39 n 25 1,028 17.0 Connecticut. ........ 32 11 8 T70 Lg. L4 Delaware............ 5 * 1 7 id District of Columbia *® * * , x 43.1 Florida............. 157 9 12 1,272 72.5 Georgia. .....ouuu... 107 % 10 480 30.2 Hawall.wevvsvvssnnss 10 * * 59 10.1 Idaho...... sutssasis a] 1 6 95 8.4 I10n0i8. cc rruassass 101 68 10 1201 99.9 Indians, «.scssinvnes 55 22 9 900 Lk9.9 ZoWBs conver snws sess 138 23 2 895 TL.2 Kansas. oovnmsnwiives 85 25 * 485 23.3 Kentucky. coisvvaans 7 5 220 29.5 Louisians... cous... 301 1 8 1,399 42.6 MBIng.c.svvnnins ive» 50 1 * 278 29.5 Maryland............ 23 3 * 55 7.1 Massachusetts....... L6 5 * 2,235 65.7 Michigan............ 17 12 2 88k 33.9 Minnesota. .......... 133 27 16 1,703 101.4 Mississippi......... 175 4 3 382 14.9 Missouri............ 462 20 4 5,172 112.9 Montans., vx vewwwmmvin 51 2 1 135 7:0 Nebraska............ 85 4 12 319 2h.2 Nevada...ovveveun... * 3 101 11.6 New Hampshire....... 58 1 * 293 k2.6 New Jersey.......... 20 16 3 358 36.5 New MexicO.......... 30 7 3 160 10.4 New Yorke. oocsvssuss 119 39 6 1,859 110.8 North Carolina...... 159 6 1h 99k 86.4 North Dakota........ 51 * * 85 2.5 OBAOceevvrssanrsssss 55 26 6 866 49.8 Ol aNOmE, vo vs sssssss 9k 25 46 292 15.0 Oregon. evevessessiis 8 15 335 36.1 Pennsylvania........ 158 3 1 T89 Ts. 9 Rhode Island........ 8 6 1 347 13:1, South Carolina...... 6 3 6 587 24.3 South Dakota........ 138 9 5 195 9.0 Tennessee. .....c..... 51 6 9 1,082 52.7 TEXAS er nnnrnnerennn. 73 105 81 4,413 96.7 Uta venmwwsvnsvrns L6 1 3 288 16.0 VETHolt ouvnnmnnacane 22 * * 88 8.3 VIP Boas vnsnaites 61 5 3 316 20.3 Washington.......... 60 10 10 1,ko6 61.2 West Virginia....... 105 3 5 Lot 54.2 Wisconsin........... 43 29 18 2,882 59.4 WYOMING. «vv vvevnnn.s i % 1 23 1.1 Guam........ Aisne 19 * * 67 6.8 Puerto Rico......... * * 2 28 3.5 Virgin Islands...... L * * 13 2.4 Source: Second Annual Report on Municipal Waste Treatment Needs by the Committee on Sewage and Waste Disposal of the Conference of State Sanitary Engineers, in cooperation with the State Water Pollution Control Administrators and the U. S. Department of Health, Education, and Welfare; Public Health Service. _1/ Estimated Cost includeg plant costs plus an allowance for interceptors and outfall sewers, which represent an investment of about 80 percent of plant cost. 111 CHRONIC CONDITIONS AND DISABILITY Charles S. Wilder and Eugenia Sullivan The U.S. National Health Survey classifies chronic conditions as illnesses and impairments which represent a departure from physical or mental well-being and which are of a type that persist for more than three months or for a long or indefinite duration. Examples of chronic conditions are heart disease and arthritis. Chronic conditions may be contrasted with "acute" conditions in which the duration of illness is generally less than three months. Examples of acute conditions are measles and influenza. Chronic conditions often result in prolonged limitation of activity. The term "activity limitation" refers not only to inability to carry on the person's major activity (working, keeping house, or going to school) but also to lesser limitation unrelated to major activity. There are T4 million persons in the United States with one or more chronic conditions. Of this number, 19 million--one out of four chronically ill persons--are limited to some extent in their activities owing to chronic disease or impairment. Leading Ccuses of Chronic Disability About one out of three persons who were limited in their activities due to chronic conditions reported heart disease, arthritis, or rheumatism as the cause. Heart conditions, the leading cause of activity limitation, were reported to have caused sbout 17 percent of all activity limitation; the second leading cause, arthritis and rheumatism, accounted for about 16 percent of the total. Mental and nervous conditions, high blood pressure, impairments of the back or spine, and impairments of the lower extremities and hips each accounted for about 7 percent of the reported activity limitation. Chart 1 Selected Chronic Conditions Causing Limitation of Activity Percent 20 Specific chronic condition causing activity limitation Percent = rong fy ree Total number of persons limited in activity Heart Arthritis Mental High Impairments, ! conditions and and blood lower impairments complete rheumatism nervous pressure extremities or partial conditions and hips Mr. Wilder is a Survey Statistician with the National Center for Health Statistics, Public Health Service; and Miss Sullivan is a Staff Assistant in the Office of Program Analysis, Office of the Assistant Secretary (for Legislation), U. S. Department of Health, Education, and Welfare. Summarizes data from "Chronic Conditions Causing Limitations of Activities," Health Statistics, PHS Pub. No. 584-B36, October 1962, based on 76,000 household interviews of the civilian non-institutional population during the 2h -month period from July 1959 through June 1961. Health, Education, and Welfare Indicators, October 1962 XZ Many Chronically Ill Persons are Limited in Major Activity About 14 million persons had chronic limitations affecting their major activity. About 2.6 million (18 percent) reported heart conditions as the cause, and 2.4 million (17 percent) reported arthritis or rheumatism. More males than females reported that they were limited in their major activity due to chronic conditions. This was true for each of the three age groups == under 45, 45-64, and 65 and over. About four million persons in the United States are so disabled by chronic illness or impairment that they are unable to carry on their ma.jor activity. Approximately one-fourth of these persons reported heart conditions as the cause of their disability. Arthritis and rheumatism and visual im- pairments ranked second and third as causes of inability to work, keep house, or go to school; 16 percent of the persons unable to carry on their major activity reported arthritis or rheumatism as the cause and 11 percent reported visual impairments. Chronic Conditions Affect One-half of the Working Population Some 30.7 million usually working persons--or about 50 percent of the working population--reported that they had one or more chronic conditions. About 4 million, or six percent of the usually working persons, were limited in thelr major activity or unable to carry on their major activity because of a chronic condition. The three leading causes of chronic limitation affecting ability to work among usually working people, heart conditions, arthritis and rheumatism, and impairments of the back or spine, accounted for 1k percent, 12 percent, and 11 percent, respectively. Chart 2 Selected Chronic Conditions Affecting Ability to Work Percent 20— oo Specific chronic condition causing limitation 15+ Percent = P—— - Total number of limited persons usually working Heart Arthritis Impairments Impairments Diseases Mental High Asthma— conditions and of back of lower of muscles, and blood hay fever rheumatism or spine extremities bones, and nervous pressure and hips joints conditions Among women keeping house, 22 million, or 61 percent, reported one or more chronic conditions. Of the total number of women keeping house, about 12 113 percent were limited in their ability to keep house or were unable to do so because of the chronic condition. Nearly one out of four women reporting such limitation named arthritis or rheumatism as the cause. Among the approximately 540,000 preschool and school-age children reported to have chronic conditions causing major limitations, 13 percent had asthma-hay fever; 11 percent complete or partial paralysis; and 6 percent, impairments (except paralysis and absence) of the lower extremities and hips. Chronic Conditions May Result in Limitation of Mobility About 4.8 million persons with chronic conditions are limited in their mobility--that is, their ability to move about freely is restricted to some degree as a result of chronic conditions. Arthritis and rheumatism caused limitation of mobility for approximately 1.1 million persons--about one out of four persons with such limitation. Heart conditions were reported by about 20 percent of those who were limited in their mobility due to chronic illness, visual impairments by 13 percent, and paralysis by 10 percent. Chart 3 Selected Chronic Conditions Causing Limitation of Mobility Percent 25 20 Specific chronic condition causing mobility limitation Percent = Total number of persons limited in mobility 10.0 Heart Arthritis Mental High Impairments, Visual Parsligis, conditions and and blood lower ex- impairments complete rheumatism nervous pressure tremities or partial conditions and hips Although a high proportion of mobility limitation is associated with arthritis and rheumatism, these conditions are more likely to cause a person to have difficulty in getting around than to confine him to the house. Heart disease and paralysis, on the other hand, are associated with a higher occurrence of house confinement. Among persons limited in their mobility because of arthritis or rheumatism, about one out of seven was confined to the house; the ratio for persons with heart disease was about one out of five, and for paralysis, one out of three. 114 Caronic Disability Increases with Age The incidence of chronic illness increases steadily with age--from 45 percent for the age group 17-UL to 61 percent for the age group 45-64, and up to 79 percent for the 65 and over group (See Table). Likewise, disability associated with chronic illness occurs more frequently among older people. Limitation in amount or kind of among chronically ill persons increases from 9 percent for the age group 17- to 17 percent and 29 percent, respectively, major EE years for the 45-64 and over-65 age groups. Inability to carry on major activity increases from 1.5 percent to L.7 percent and 19.7 percent for the three age groups; and limitation of mobility increases from about 2 percent to 6 percent and 23 percent. As age increases certain disease groups assume a relatively increased importance as caused of chronic disability. blood pressure, arthritis and rheumatism, and visual impairments are likely to increase in severity, as well as Prevalence, among older persons. arthritis or rheumatism and visual im- palrments were reported as causing respectively about 2Uk, 23, and 10 percent of Among persons under 45 years of age, these three condition groups were reported to have caused 6, 5, and 3 percent respectively, of the total number of limitations. aged 65 and over, heart conditions, the limitations. Limitation of Activity and Mobility Due to Chronic Conditions July 1959 - June 1961 In particular, heart disease, high Among persons Age Group Average Number (in thousands) Percent Distribution Category ATL Under 65 and | A11 Under 65 and Ages 17 17-bL | 45-64 | Over Ages | 17 17-4k | 45-64 | Over Total Population 176,302 | 61,911 | 63,068 | 35,989 15,334 | 100.0 [100.0] 100.0 | 100.0 | 100.0 Persons with no chronic conditions 102,453 | 50,795 | 34,473 | 13,921| 3,265 58.1 | 82.0 Sh. 38.7 21.3 Persons with one or more chronic conditions 73,849 | 11,116 | 28,5% | 22,068 | 12,070 k.9| 18.0 45.3 61.3 78.7 Limiting Activity: 19,273 | 1,120 4,652 6,593] 6,908 10.9 1.8 7.4 18.3 45.1 Other than major activityl 5,056 580 1,630 1,803 1,043 2.9 0.9 2.6 5.0 6.8 Amount or kind of major activit; 10,243 Lot 2,600 3,745] 3,491 5:8 0.7 Lh. 10.4 22.8 Unable to carry on major activit; 3,974 133 Loz 1,045 | 2,374 2.3 0.2 0.7 2.9 15.5 Limiting Mobility: 4, 766 199 509 1,331] 2,726 2.7 0.3 0.8 3:7 37:8 Having trouble getting around alone 2,843 77 327 915| 1,523 1.6 OG. 0.5 2:5 9.9 Unable to get around alone 1,008 72 97 220 619 0.6 sl 0.2 0.6 k.o Confined to house 915 50 85 196 584 0.5 0.1 0:3 0.5 3.8 1/ Major activity refers to ability to work, keep house, or go to school. 115 MENTAL RETARDATION Luther W. Stringham Mental retardation is a condition, characterized by the faulty development of intelligence, which impairs an individual's ability to learn and to adapt to the demands of society. The failure of intelligence to develop normally may be due to diseases or conditions--occurring before or at the time of birth, or in infancy or childhood--that damage the brain. It may also be due to factors determined by heredity that affect the development of the brain. It is sometimes accentuated by home or social conditions which fail to provide the child with adequate stimulation or opportunities for learning. Degrees of Retardation The degree of retardation varies greatly among individuals. It can be so severe that the afflicted person must have protective care throughout his life. In others the retardation is so mild that many tasks can be learned and a measure of independence in everyday life can be achieved. In a substantial number of cases the affected persons can adjust in a limited way to the demands of society, and in many instances can, with help, become productive members of the labor force. There is no fully satisfactory way of characterizing the degrees of retardation. They range, according to one classification, from pro- found to mild, and are related to intelligence quotient (1.Q.), develop- mental characteristics, potential for education and training, and social and vocational adequacy as shown in the following table: Mr. Stringham is the Director, Office of Program Analysis, Office of the Assistant Secretary (for Legislation) and Chairman of the Department's Committee on Mental Retardation. This article was prepared with assistance from members of the Secretary's Committee on Mental Retardation and the staff of the President's Panel on Mental Retardation. Additional informa- tion is included in Mental Retardation Activities of the U. S. Department of Health, Education, and Welfare, (May 1962), U. S. Government Printing Office, Washington 25, D. C. Health, Education, and Welfare Indicators, June 1962 116 Developmental Characteristics of the Mentally Retarded Degrees of Pre-School Age School Age Adult Mental Re- 0-5 6 - 20 21 and over tardation Maturation and Training and Education Social and Vocational Development Capabilities Profound Gross retardation; Some motor development Some motor and speech I.Q. minimal capacity for present; cannot profit development; totally below 20) functioning in from training in self- incapable of self- sensorimotor areas; help; needs total care. maintenance; needs needs nursing care. complete care and supervision. Severe Poor motor develop- Can talk or learn to Can contribute par- (7-0. ment; speech is mini- communicate; can be tially to self- 20-35) mal; generally unable trained in elemental support under com- to profit from train- health habits; cannot plete supervision; ing in self-help; learn functional ac- can develop self- little or no communi- ademic skills; profits protection skills cation skills. from systematic habit to a minimal useful training. level in controlled environment. Moderate Can talk or learn to Can learn functional Capable of self- (I.Q. communicate; poor academic skills to maintenance in un- 36-52) soclal awareness; approximately 4th skilled or semi- fair motor develop- grade level by late skilled occupations; ment; may profit from teens if given special needs supervision self-help; can be education. and guidance when managed with moderate under mild social supervision. or economic stress. Mild Can develop social Can learn academic Capable of social and (1.Q. and communication skills to approxi- vocational adequacy 53-68 skills; minimal re- mately 6th grade with proper education tardation in sensori- motor areas; rarely distinguished from normal until later age. level by late teens. Cannot learn general high school subjects. Needs special educa- tion particularly at secondary school age levels. 17 and training. Fre- quently needs super- vision and guidance under serious social or economic stress. Another classification, used in relation to educational programs, makes use of a three-way division as follows: Level Intelligence Quotient I. Custodial Below 25 II. Trainable About 25-50 ITI. Educable About 50-75 Other classifications group the retarded in somewhat different ways and make use of other terminology. Nevertheless, all of them recognize gradations of mental retardation, although the exact boundary lines vary. Regardless of the particular classification used, however, it should be understood that seldom, if ever, is I.Q. the only deter- mining factor in mental retardation. Other factors that affect intel- lectual competency are emotional control and social adaptability. The Causes of Mental Retardation Based on present knowledge the causal factors in mental retard- ation may be divided into two broad categories: (1) mental retardation caused by incompletely understood psychological, environmental, or genetic factors without any evident damage of the brain; and (2) mental retardation caused by a number of specifically identified conditions or diseases. The causal and contributing factors included in each of these categories are as follows: 1. Mental retardation caused by incompletely understood psychological, environmental, or genetic factors without any evident damage of the brain. This group contains T5 to 85 percent of those diagnosed as re- tarded. It consists of individuals who show no demonstrable gross ab- normality of the brain and who, by and large, are persons with relatively mild degrees of retardation. In general, the prevalence of this type of retardation is greater within the less favored socioeconomic groups within our culture. A variety of factors may be operating within this large category. Tt is believed that some members of this group are products of very complex mechanisms of heredity, reflecting the fact that human beings show genetic variability in any characteristic, including measured intelligence. Environmental factors such as the psychological circum- stances of life, social interaction patterns, and the richness of the environment with respect to intellectual stimulation play an important definitive or contributory role within this group. Finally, a variety of unfavorable health factors--including maternal health and prenatal care, nutrition, the conditions of birth, and other illnesses or injuries which may produce minimal and undemonstrable brain damage-- probably contribute to a lower level of performance in many cases. 118 The total effect, thus, is a complex one, involving the action or the interaction of genetic factors, psychological experiences, and environmental influences. At the present time, it is impossible to assign clear weights to each of these general causative factors. It is known that all of them, however, operate more strongly in the under- privileged groups than among those more favorably situated in society. The prospects for prevention and amelioration should not be discourag- ing, however, since many of the environmental and psychological variables are subject to control, opening up the possibility of preventing some of the retardation, especially of milder degree, based upon this class of causation. Some of these conditions are preventable if treatment can be instituted early enough in the child's life. Most of the remainder can be ameliorated through a combination of resources, medicine, social work, education, and rehabilitation. It should be very clearly stated that these same factors also affect retarded individuals whose difficulty stems from the more specific etiologies enumerated in category 2 below. 2. Mental retardation caused by specifically identified conditions or diseases in which there is demonstrable brain damage. In approximately 15 to 25 percent of diagnosed cases of mental retardation, a specific disease entity can be held responsible. The impact of such diseases can be most readily demonstrated in those in- stances where there has been gross brain damage and where the degree of retardation is severe. As mentioned above, it is uncertain to what extent these "organic" factors may operate to produce minor impairment among the less severely retarded groups. Such "organic" factors fall within seven general classes: a. Diseases due to infections in the mother during pregnancy or in the infant after birth. German measles, occurring during the first three months of pregnancy, is known to result in mental retard- ation as well as other abnormalities. Other infections occurring during pregnancy have also been implicated. A number of the infectious diseases of infancy and childhood may cause brain injury resulting in retardation. b. Brain damage resulting from toxic agents which are ingested by the mother during pregnancy or by the child after birth. Jaundice of the newborn due to Rh blood factor incompatibility and carbon monoxide or lead poisoning are examples. c. Diseases due to trauma or physical agent. Brain injury occurring as a result of difficult delivery and asphyxiation due to delay in the onset of breathing at the time of birth are common causes. They occur with particular frequency in premature babies. Brain injury in childhood, especially from automobile accidents, is an added factor. 19 d. Diseases due to disorders of metabolism, growth or nutrition. A number of disorders of metabolism, some of which are determined by heredity, produce mental retardation. Some of the most important of these disorders are phenylketonuria and galactosemia in which there are abnormalities of amino acid chemistry in the body. e. Abnormal growths within the brain. A number of rare conditions, some determined by heredity, are characterized by tumor- like and other abnormal growths within the brain and produce mental retardation. f. Diseases due to unknown prenatal factors. Recent discoveries prove that mongolism results from abnormal grouping of chromo- somes probably at the time of formation of the ovum in the mother. Other congenital malformations have a similar basis. For some, however, an undetermined prenatal mechanism must be responsible. g. Diseases due to uncertain causes but with evi- dent damage of the brain. A sizable group of mentally retarded children have evident damage to the brain which is presumed to be linked to the mental retardation. The causes of the pathology of the brain in this sizable group remains unknown. Data on patients in institutions show a higher prevalence of patho- logical conditions among the more severely retarded. Retarded children have other defects more often than the average child. They are often smaller than average, and have poorer muscular coordination. They have a greater than ordinary percentage of defects, such as hearing and vision, and have probably greater difficulty in perceiving what the sense organs bring to their minds. Thus many of them are multihandicapped in some degree. Scope of the Problem As stated above, mental retardation is defined as impairment of ability to learn and to adapt to the demands of society. These demands are not the same in every culture. In fact, even within our own commun- ity they vary with the age of the individual. We expect little, in terms of intellectual pursuits, from the preschool child. During the school age, the individual is evaluated very critically in terms of social and academic accomplishment. In later life, the intellectual basis of social inadequacy again may be less evident. Numerous surveys directed toward determining the frequency and magnitude of the problem of mental retardation have shown that the number of individuals reported as retarded is highest during the school age. Less than one-fifth as many children in the age group O-4 were reported by these surveys as mentally retarded as were reported in the age group 10-14%. Similarly, only one-fourth as many persons in the age group 20 and over were identified as mentally retarded as compared with the number identified in the age group 10-1k. This varying prevalence by age is to some extent determined by differential survival rates and other demographic factors. However, the very high prevalence at ages 10 to 14 is due primarily to the in- creased recognition of intellectual handicap of children within the school systems. The very low number of infants from O to 1 year old identified as retarded is in part at least due to the fact that their intellectual deficiency 1s not yet apparent. Only gross impairment is evident in early childhood. Of striking significance is the fact that half of the individuals considered retarded during adolescence are no longer so considered in adulthood. In view of these considerations, only the most crude estimates of the overall magnitude of the problem can be established. One such estimate may be derived through the use of intelligence quotients, and obtained from the samples upon which our intelligence tests have been standardized. The numbers of mentally retarded persons by this criter- ion can be calculated roughly on the basis of this experience with in- telligence testing. On most tests standardized nationally, experience has shown that virtually all persons with I.Q.s below about 70 have significant difficulties in adapting adequately to their environment. About 3 percent of the population score below this level. Based on this figure of 3 percent, it is estimated that, of the 4.2 million children born each year, 126,000 are, or will be, classed as mentally retarded. Of the 126,000, some 4,200 (0.1 percent of all births) will be retarded so profoundly or severely that they will be unable to care even for their own creature needs. About 12,600 (0.3 percent of all births) will suffer from "moderate" retardation--they will remain below the T-year intellectual level. The remaining 110,000 (2.6 percent of births) are those with mild retardation and represent those who can, with special training and assistance, acquire limited job skills and achieve almost complete independence in community living. Applying these same percentages to the total population it is estimated that there are approximately 5.4 million mentally retarded persons in the population. Of this number: - 60,000 to 90,000 are persons, mostly children and adolescents, so profoundly or severely retarded that they cannot survive unless constantly cared for and sheltered. 300,000 to 350,000 are moderately retarded children, adolescents, and adults who can assist in their own care and can even undertake semi-productive endeavors in a protected environment. They can understand the meaning of danger. However, they have limited capacity to learn, and their shortcomings become evident when they are called upon to understand the meaning of svmbols as used in the written language. These people can learn many tasks when patiently and properly taught. + Some 5,000,000 are mildly retarded children, adolescents, and adults who are able to perform more adequately, adjust in a limited way to the demands of society, and play a more positive role as workers. Economic Costs of Mental Retardation There are no reliable estimates of the total cost to the Nation, both direct and indirect, of mental retardation. The direct costs to families and to communities include those for institutional and home care and for special services. Indirect costs include the losses that result from the absence of earning capacity and inability to contribute to the production of goods and services. Only 4 percent of the mentally retarded are confined to insti- tutions. Yet, their care costs relatives and communities some $300 million annually. Additional amounts are required for the construction of facilities for custodial and educational purposes. The cost of institutional care, facilities construction, and special care in the family home totals more than $1 billion per year. The Development of National Concern Mental retardation thus is a serious problem affecting many aspects of our society. The host of problems presented by these people-- to themselves, to their families, and to their communities--include biological, psychological, educational, vocational, and social areas of concern. Mental retardation must be approached through the whole life cycle, from consideration of genetics and conception through pregnancy, delivery, childhood, adolescence, adulthood, and old age. Since 1950, interest in the problem of mental retardation has grown very rapidly. During the past decade increased activities have been stimulated by a few foundations, by the demands of parents, by interested lay and professional groups, and by members of legislative bodies who have been convinced of the urgent need for programs in this field. Today, private efforts and public programs at all levels of govern- ment--local, State, and Federal--take eight basic forms: 1. Diagnostic and clinical services. There are over 90 clinics specializing in services to the retarded. Well over half were established within the past five years. These services need still greater expansion. The 20,000 children aided in 1960 represent only a small fraction of those who need the service. 2. Care in residential institutions. Today there are over 200,000 mentally retarded patients in such institutions, approxi- mately 10 percent more than there were five years ago. But the average walting list continues to grow, and the quality of the service often suffers from limited budgets and salary levels. Increases in both facilities and manpower are necessary. 3. Special education. The number of mentally retarded enrolled in special educational classes has been doubled over the past decade. In spite of this record, we are not yet meeting our existing requirements, and more such facilities must be provided. Less than 25 percent of our retarded children have access to special education. Moreover, the classes need teachers specially trained to meet the specialized needs of the retarded. To meet minimum standards, at least 75,000 such teachers are required. Today there are less than 20,000, and many of these have not fully met professional standards. 4. Parent counselling. Counselling of parents is now being provided by private physicians, clinic staffs, social workers, nurses, psychologists, and school personnel. Although this service is still in an experimental stage of development, it offers bright prospects for helping parents to meet their social and emotional problems. >. Social services. Social services provided mentally retarded children and adults include case work, group work, and day care. These services are an integral part of clinical, rehabilita- tion, and other mental retardation programs. Social workers are also active in community organizations and in working with parents groups. 6. Vocational rehabilitation. In the past five years the number of mentally retarded rehabilitated through State vocational agencies has more than tripled--going from 1,094 in 1957 to 3,562 in 1961. In terms of the number who could benefit from rehabilitation services, this number is very small. However, new knowledge and new techniques are needed, for over 25 percent of those coming out of the special classes still cannot be placed. fT. Preparation of professional personnel. The Federal government is now promoting the training of leadership personnel in education, rehabilitation workers, research personnel, and medical and welfare specialists. In addition, programs are being provided that will increase the competence of the health professions in providing services for retarded persons. Nevertheless, shortages of qualified personnel remain one of the major bottlenecks in providing services to retarded persons and their families. 8. Research. Support for research in the causes and amelioration of mental retardation has been greatly increased, espe- cially during the last five years. Progress has been made in identi- fying specific conditions and diseases and in establishing basic prob- lems of behavior and learning, but major research breakthroughs must be achieved before there will be adequate understanding of the patho- logical, genetic, psychological, environmental, and other aspects of mental retardation. 123 Programs of the Federal Government Primary responsibility within the Federal government for activi- ties relating to mental retardation is located in the Department of Health, Education, and Welfare. Within the Department these programs are administered by four operating agencies--the Public Health Service, Office of Education, Social Security Administration, and Office of Voca- tional Rehabilitation--and may be grouped under four main categories: (1) research and studies; (2) professional preparation; (3) services; and (4) construction of a limited number of facilities that qualify for assistance under the hospital and medical facilities construction (Fill- Burton) program. Research activities include (1) the intramural and extramural support programs of the National Institute of Mental Health, the National Institute of Neurological Diseases and Blindness, and the Center for Research in Child Health of the Public Health Service; (2) the Office of Education programs of studies, surveys, and cooperative research; (3) special project grants under the maternal and child health program of the Children's Bureau, Social Security Administration; and (4) the research and demonstration projects of the Office of Vocational Rehabili- tation. Professional preparation is supported through (1) Office of Voca- tional Rehabilitation grants to educational institutions for training of personnel for all phases of rehabilitation; (2) teaching and training grants of the National Institutes of Health; (3) intramural training programs of the Public Health Service; and (4) Office of Education train- ing grants to colleges and universities and State educational agencies for leadership positions in the education of the mentally retarded. Services include consultation and technical assistance in their respective areas of competence by (1) the Children's Bureau, under the maternal and child health and the child welfare services programs; (2) Office of Vocational Rehabilitation to State rehabilitation agencies; (3) the National Institute of Mental Health through its regional office staffs; and (4) the Office of Education to State and local school sys- tems, educational personnel and voluntary groups. In addition, finan- cial assistance to States is provided under the Federal-State programs of public assistance, and benefit payments for the disabled are made under the Federal program of old-age, survivors, and disability insurance. In the 1963 fiscal year the Department of Health, Education, and Welfare anticipates expenditures in excess of $28 million from general funds for research, training, and services in the field of mental retardation. This total represents an increase of $4.3 million over the estimated level of funds available for this purpose for fiscal year 1962 and more than doubles the $12.4 million spent by the Department five years ago. In addition, it is estimated that over $63 million will be 124 paid from the old-age, survivors, and disability insurance trust funds to persons with diagnosed mental deficiency--primarily adults who have had disabilities from childhood. Mental Retardation and the Future The acceleration of effort--private and public--already has pro- duced some encouraging results. Progress has been made in identifying specific disorders and their treatment, in training personnel, in pro- viding additional facilities, and in improving services generally. Special education classes have multiplied. More rehabilitations have been completed. Parents get better counseling. Even though such progress is gratifying, mental retardation will continue to be a problem of national concern. Unless there are major advances in methods of prevention, there will be as many as one million more mentally retarded persons by 1970. Improved and more extensive prenatal, obstetrical and pediatric care have brought about marked increases in the infant survival rate in the Nation over the past 20 years. Such efforts, along with increasing the chances of survival of all infants, have also increased the survival retes of infants who are premature or who have congenital handicaps or melformations. Since mental retardation is one of the major conditions associated with such handicaps in infants, improved care has to an ex- tent also increased the number of the retarded for whom special services will be needed. Disease control, new drugs, and higher standards of living have steadily increased the life span of most Americans. While the mentally retarded as a group fall below the average life expectancy, the number of years the average retarded individual lives has been increasing pro- portionately with the overall average. This increase in life span adds meterially to the number of mentally retarded persons, particularly in the upper age levels. With the increased availability of health services, the life span of mentally retarded persons may continue to increase and move closer to the average life expectancy of the general population. The increased survival rates of retarded infants will probably bring with it an increase in the number of retarded persons who have associated physical handicaps. Current reports from clinical programs dealing with retarded children under 6 years of age indicate that even now in this group, 75 percent have associated physical disabilities. Likewise, because the older individuals are now living longer, we can expect many of them to present the physical problems of the aged in the general population. Because of changing social and economic conditions, some of the problems of mentally retarded persons will become more acute in the future: 125 1l. Families are growing larger and in fewer instances will a retarded child be an only child. 2. More mothers of young children are in the labor force. Many times the factors that induce mothers to work are even more force- ful for the mother who has a retarded child. Substitute care for the retarded child, however, is more difficult to obtain. Frequently, too, the retarded child is less able to understand the need for a parent substitute, which makes planning more difficult to carry out. 3. More children are going to school longer. The general level of education is rising in the Nation. As this trend continues, the mentally retarded whose disability shows itself in this area will be more marked. As educational standards and achievements continue to rise, a greater number of individuals who cannot keep up or achieve these levels will be discovered and will demand attention. 4. Machines replace unskilled labor. In the past, the majority of the mentally retarded children completing special classes for the educable in urban areas were able to find jobs on their own. There is some question whether this will continue to be so in the next 10 years without additional special help. Increased industrial specialization, automation and the intensified tempo of industrial production, pose new problems. Elevated educational standards in rural areas also are adding to the problem. Farming, which years ago provided a field of employment for many of the retarded, has become so highly specialized that persons who would have been employed in the past have a difficult time finding employment at all now. The President's Panel on Mental Retardation Thus the problem of mental retardation presents a major challenge to society: to find causes, to seek prevention, and to provide the best possible assurance for lives of maximum usefulness. Manifestly, the needs remain great for more knowledge, more personnel, more facilities, and more services. In October, 1961, President Kennedy appointed a panel of physicians, scientists, educators, lawyers, psychologists, social scientists and other leaders to review present programs and needs, to ascertain gaps, and to prescribe a program of action. The President has asked the Panel to formulate a national plan to combat mental retardation and to report to him on or before December 31, 1962. The Panel's recommendations will pro- vide the guidelines for future efforts and further progress in the years to come. 126 REPORT OF THE PRESIDENT’S PANEL ON MENTAL RETARDATION Leonard W. Mayo President Kennedy appointed the Panel on Mental Retardation in October, 1961, with the mandate to prepare a national plan to help meet the many rami- fications cf this complex problem. In October, 1962, the Panel presented its report, which was subsequently published early in 1963. The 200-page document includes over 90 recommendations. Mental retar- dation is shown to be a major national health, social and economic problem affecting some 5.4 million children and adults and involving some 15 to 20 million family members in this country. It estimates the cost of care for those affected at approximately $550 million a year, plus a loss to the Na- tion of several billion dollars of economic output. In carrying out its mandate, the Panel employed four main methods of study and inquiry: * Task forces on specific subjects were appointed to which all mem- bers were assigned and advisors were designated to work closely with them. * Public hearings were held in seven major cities, at which public officials concerned with retardation, teachers, representatives of related professions, parents, and others reported on local and state programs and gaps in service and made recommendations. * Panel members and advisors visited England, Sweden, Demmark, Holland, and the Soviet Union to study methods of care and education of the retarded and to become acquainted with research in those countries. * A considerable body of literature and recent studies were reviewed, and Panel members visited and observed facilities and programs for the re- tarded in several states. Highlights of the findings and recommendations in each of the main sections of the report are summarized herewith, with liberal quotations from the text. Mr, Mayo was the Chairman of the President's Panel on Mental Retardation. See also the author's "Report" for the National Rehabilitation Association's Journal of Rehabilitation, Nov.-Dec. 1962. Mr. Rudolf P. Hormuth, Specialist in Services for Mentally Retarded Children, Children's Bureau, prepared "Highlights" from the report for the Jan.-Feb. 1963 issue of Children (reprints available). The report itself, A Report of the President's Panel on a Proposed Program for National Action to Combat Mental Retardation, may be purchased from the U. S. Govermment Printing Office, Washington 25, D. C., at 65 cents. Some of the basic facts relating to the size of the problem, causal factors, and necessary services are contained in "Mental Retardation' in the June 1962 issue of Indicators (reprints available). Health, Education, and Welfare Indicators, February 1963 127 Research In research, the Panel recommends that: + Ten research centers affiliated with universities be established to insure continuing progress in research relevant to mental retardation in both the behavioral and biological sciences and to provide additional facili- ties for training research personnel. + Biological and behavioral research as presently conducted by indi- vidual investigators interested in problems germane to mental retardation be continued and extended. + Population studies be undertaken as a basis for analyses of the characteristics and needs of the mentally retarded population on a national basis. + Governmental activity in developing plans for storage, retrieval, and distribution of scientific data be continued. «+ Congress provide funds to improve the serious shortage of labora- tory space; private foundations are requested to review their policies and to consider grants designed to help alleviate this problem. + Scientists in both the biological and behavioral groups engage in highly specialized conferences to deal in depth with problems underlying re- tardation. © A Federal Institute of Learning be established under the general auspices of the Department of Health, Education, and Welfare (HEW). + The research budget for exceptional children in the U.S. Office of Education be augmented in accordance with the provisions of legislation pro- posed in 1962. + The National Institutes of Health and private foundations provide more post-doctoral fellowships, awards, and research and career professor- ships in fields relevant to retardation. + Programs to train research educators, sociologists, and psycholo- gists in mental retardation be initiated. + Federal support be undertaken for a national program of scholarships for undergraduate college students possessing exceptional scientific ability and for the extension of research activities in undergraduate science depart- ments. + An extensive program of federal aid to education be designed to prevent loss to the scientific manpower pool of numbers of gifted youths who fail to enter college for financial reasons. + The graduate fellowship program in the U.S. Office of Education be extended to provide for preparing research specialists in the education of the mentally retarded. 128 Prevention To develop a program to prevent mental retardation, the Panel proposes that: - All possible federal, state, and local resources be mobilized to provide maternal and infant care in areas where prematurity rates are high and the consequent hazards to infants great. - High priority be given to making adequatematernal care accessible to the most vulnerable groups in our society, i.e., those who live in seriously deprived areas and who receive little or no medical care before, during, or after pregnancy, and that funds be substantially increased under Title V, Part 1, of the Social Security Act (Maternal and Child Health), to provide for such care. - State departments of health and university medical centers collabo- rate in the development of multi-state genetic counseling services in order to give young married couples and expectant parents access to such consul- tation, and that diagnostic laboratories for complex procedures (related to prevention) be developed. + The present review of drug testing procedures be endorsed and the current policy with respect to the distribution of drugs to physicians for field trials without adequate criteria or preparation be investigated. - Laws and/or regulations be enacted by all states (as they have by some) to provide for the registration, inspection, calibration, and licensing of X-ray and fluoroscopic machines and other ionizing radiation sources; and that lifetime radiation records be developed on a demonstration basis in se- lected areas for the recording and dating of diagnostic and therapeutic X-ray exposure. - Hospitals adopt every known procedure to ensure the prevention of prenatal and neonatal defect and brain damage, and that they apply modern child-rearing knowledge and practices in dealing with infants who may have suffered from trauma resulting from maternal separation. + Programs keyed to the needs of culturally deprived groups in speci- fic areas be organized to reduce the impact of deprivation, which seriously affects the development of children's learning ability. State departments of health, education, and welfare are asked to join in promoting local com- munity programs of prevention to offset the adverse effects of destructive community and neighborhood environment. + A domestic Peace Corps be established to help meet the personnel shortage and special needs in deprived areas and to give Americans an opportunity to serve their own and other communities effectively. 129 Clinical and Medical Services In this area, the Panel recommends that: * Inclusive programs of clinical services and medical care be made available to the retarded in or close to the communities where they reside. State and local health departments are urged to extend their services to children in the lower socioeconomic groups and to utilize procedures for the early detection of abnormalities. * Every related agency in the community include the mentally re- tarded and their families among those served. * State governments lift all present restrictions preventing retar- ded children with physical handicaps from receiving services available to all other physically handicapped children in the state crippled children's program; to make this possible, an increase of federal funds to the crippled children's program (Title V, Part 2, Social Security Act) earmarked for the mentally retarded is recommended. * Additional clinics for the retarded be established wherever needed to provide services for additional patients and opportunities for training personnel. « To plan these program services more effectively, it is essential that adequately staffed biostatistical sections at the state and federal levels be developed; that there be improved record-keeping and data pro- cessing systems; and that community and epidemiological studies be designed and carried out. Education The Panel recommends that specialized educational services be extended and improved to provide appropriate educational opportunities for all retar- ded children. This assistance, the report states, can be provided through a federal Extension and Improvement (E & I) program, administered to assure the use of available funds for expansion or development of new services rather than for existing programs at current levels. Any proposal to extend or improve spe- cial educational services for retarded children should be considered for an E & I grant, and evaluated on a competitive basis. Universities, state de- partments of public education, local and county school systems, and other edu- cational agencies should all be eligible to submit such applications. 130 At present, states usually assist local school systems by reimbursing local districts for a portion of the excess cost of providing special educa- tion services; however, the amount available for this purpose in the budget of the state departments of public instruction is usually limited. Any sub- stantial extension of the specialized educational services for retarded children will require assistance and stimulation from sources beyond local and state school systems. It is essential that adequate opportunities for learning intellectual and social skills be provided such children through formal pre-school educa- tion programs designed to facilitate adequate development of skills such as speech and language, abstract reasoning, problem solving, etc., and to effect desirable patterns of motivation and social values. Most retarded children live in city slums or depressed rural environ- ments. Research suggests that deprivation of adequate opportunities for learning contributes to and complicates the degree of mental retardation present in these children. Formal pre-school programs of increased learning opportunities may accelerate development of these children. Yet there are exceedingly few such programs now available to enrich the experiences of de- prived pre-school children. The Panel suggests that instructional materials centers be established in the special education units of state departments of public instruction or in university departments of education, to provide teachers and other educa- tion personnel with competent consultation on instructional materials and to distribute and loan such materials for the mentally retarded. The Panel strongly recommends that specialized classroom services be. extended to provide for all mentally retarded children. Additional special class services are required for all age levels for both educable and train- able retarded children. However, it is doubtful that comprehensive programs will be developed in most communities without the additional incentive of external financial support, provided by the federal government through the E & I program. The Panel suggests that services of educational diagnosis and evalua- tion be extended to all school systems to provide for early detection of school learning disabilities and to enable appropriate school placement. The U.S. Office of Education is urged to increase its administrative leadership and staff of the program for exceptional children to a level com- mensurate with the importance of exceptional children in the nation's program of public education. The Panel underlines the need for an additional 55,000 trained teachers of the mentally retarded. If fully implemented, the Panel states, the fol- lowing program would add 6,000 new teachers each year to the pool of skilled teaching specialists in retardation: 131 + Government and private foundations should provide annually $9 million to be awarded to universities to provide scholarships and to support the training program. + Fach state should appropriate an amount equal to at least 5 percent of its annual budget for special education for training grants to experienced teachers wishing to specialize in.mental retardation. It is recommended that the government match the funds allocated by the state departments of public instruction. + Local school systems (by granting leave-of-absence with pay), com- munity agencies, and civic organizations should contribute to the education of those who will teach their retarded children. Concerted effort on the part of these local groups should enable them to achieve the reasonable objective of a contribution of $3 million annually--an average of $1,000 from each of the 3,000 local school systems now operating programs for the retarded. The Panel also urges that methods be developed to provide for more effective training and use of personnel for teaching retarded pupils. Re- search and demonstration projects should be initiated to determine staffing patterns to conserve teaching manpower. It is recommended that the Fellowship Program under Public Law 85-926 be extended to include provisions for preparing research specialists. Funds are currently available under Public Law 85-926 for the preparation of ad- ministrators, supervisors, and college and university instructors in special education, excluding, however, persons who wish to prepare for research careers. Vocational Rehabilitation Recent progress in vocational rehabilitation must be tempered by recog- nition that only about 3,500 retarded persons were reported as rehabilitated under the federal-state program over the past year. This figure is negli- gible when compared with even the most conservative estimate of the retarded who could benefit from this service. The Vocational Rehabilitation Adminis- tration (VRA) is deeply interested, however, and has been active for some time in developing this aspect of its program. If the present need were being met in full: + 75,000 retarded youth in their final year of schooling would be receiving services such as prevocational counseling and evaluation, and job placement. + 19,000 retarded youth would be receiving post-school preparation for competitive work in an employment training center or comparable facility. + 120,000 moderately retarded adults would be receiving services and working in workshops or similar places. «+ 75,000 severely retarded adults living in communities would be re- relying. Soruties in facilities providing training in basic living skills, recreation, etc. 132 In the future the demand for vocational rehabilitation services will increase. Opportunities for jobs traditionally identified with the retarded are on the decrease. Competition for these jobs is becoming keener as unskilled workers, displaced by automation, seek jobs once held almost exclusively by the retarded. Adverse effects of recessions are likely to be felt more acutely by mentally retarded than by nonretarded workers. The Panel recommends that vocational rehabilitation services for retarded youth and adults be expanded through earmarking of federal funds under the federal-stage program of vocational rehabilitation. If the productive capacities of the nation's mentally retarded are to be realized, every retarded youth must have the following services avail- able to him prior to, during, and after termination of his formal education: vocational evaluation, counseling, and job placement; training courses in appropriate vocational areas; joint school-work experience programs co-sponsored by schools and vocational rehabilitation agencies; clearly defined and ade- quately supervised programs for on-the-job training; employment training facilities; sheltered workshops; vocational rehabilitation services in con- junction with residential institutions; and counseling services to parents. The report also calls for a federal program to provide financial support for constructing, equipping, and initially staffing sheltered work- shops and other rehabilitation facilities, through VRA. Comparable programs for other types of facilities exist in other agencies of government and have, in general, proven highly effective. The Hill-Burton Act is the legal basis for one such program. The Panel also suggests that VRA be given responsibility for leadership in planning, developing, coordinating, and supervising a system of sheltered work programs. The programs themselves should be operated by voluntary and public agencies with assistance from state and federal rehabilitation agencies; they should be developed in stages with small-scale pilot projects serving as a base for expansion. Hopefully, this would lead eventually to the establish- ment of sheltered work programs in every major urban community in the nation. Residential Care In this area, the report recommends that: * Every residential facility be: an integral part of a state-wide program for the retarded and closely related to the community; basically thera- peutic or educational, and closely linked to appropriate community medical, education, and welfare programs; operated under flexible admission and release policies, similar to those of a hospital or school; and equipped to undertake research in some form as a part of its program. * Admission to residential care be reserved for those whose specific needs can best be met via such a facility. 133 + Appropriate authorities in every state determine the status of all mentally retarded patients in state hospitals for the mentally ill at regular intervals and remove those who can profit by care designed primarily for the retarded. * Upon presentation of plans meeting criteria established by the Secretary of Health, Education, and Welfare, matching grants be provided to the states for institutions to facilitate planning and development, recruiting and training personnel, and research. + No institution for the retarded accommodate more than 1,000, and units now being planned for future construction not exceed 500 beds. The Law and the Mentally Retarded The Panel approaches this problem from the point of view that, with the development of new alternatives in treatment, it should now be possible to overcome certain rigidities of the law in the interest of giving the re- tarded individual the benefit of modern knowledge. The Panel suggests that mandatory legal requirements be minimized wherever voluntary compliance can be obtained. The question of formal legal intervention is regarded as a resi- dual resource which should not be utilized where social or personal interests can be adequately served through other means. This section of the report, nonetheless, points out that the law must protect the rights of the retarded. Like other citizens they must be assumed to have full human and legal rights and privileges. The mere fact of mental retardation should never be considered in and of itself sufficient to remove their rights. The Panel recommends specifically that: * Each state establish or designate a protective agency for the re- tarded, to provide for consultation for them and their families and for em- ployers, guardians, and others concerned with their social and legal problems, and to supervise the private guardians of retarded persons. * Superintendents of residential facilities for the retarded accept as ''voluntary'" admissions only those adults who are capable of making such a decision. + No limited guardian of a mentally retarded adult be able to commit his ward to an institution without a judicial hearing unless the court order appointing the guardian gave him such discretion--in which case he should inform the court of his ward's change of residence. 134 * Since state and local school authorities are constitutionally obliged not only to provide education for educable mentally retarded child- ren, but also to provide training facilities and personnel for trainable mentally retarded children, these authorities re-examine the extent to which they provide education and training for mentally retarded children. * The court in deciding whether a confession to a crime was coerced-- and hence inadmissible at trial-- consider all the relevant circumstances, and assess whether the mentally retarded defendant's state of mind was such as to preclude the confessions being voluntary in any meaningful sense; and that caution be taken against giving any probative weight to the fact that a mentally retarded defendant remained silent when accused of a crime. * The mentally retarded individual who exhibits persistent uncontrolled behavior threatening the well-being of others requires special attention, which should be a subject of special study, since he is unsuited both to the typical prison and to most residential facilities for the retarded. Local, State, and Federal Organization Concerning local, state, and federal organization and relationships, the Panel recommends that: * There be available to every retarded person either in his community or at a reasonable distance: a person, committee, or organization to whom parents and others can turn for advice and counsel; life counseling services; and a sufficient number of qualified professional and informed nonprofessional people willing to assist in developing a program for an individual, and in developing a local or state program. * Every health, education, and welfare agency provide a person, office, division, or other appropriate instrumentality to organize and be responsible for those agency resources or services relevant to mental re- tardation; and those agencies dealing with the retarded at a local, community, or state level establish committees with high level representation to facili- tate communication and cooperation. * A formal planning and coordinating body made up of all appropriate segments of the community be established with the mandate to develop and coordinate programs for the retarded. + The federal government take leadership in developing model com- munity programs for the management of mental retardation in each of the Department of Health, Education, and Welfare regions. The objectives of such models would be: to develop concrete examples and demonstrations of what is believed to be the best possible care for the retarded on a coordi- nated basis; and to provide teaching resources in which present and future administrative and professional personnel could receive higher quality training. © The Secretary of Health, Education, and Welfare should be authorized to make grants to states for comprehensive planning in mental retardation. 135 MANPOWER FOR MEDICAL RESEARCH Herbert H. Rosenberg and Luther W. Stringham Medical and health-related research comprises a broad area of scientific inquiry aimed at the improvement of human health and the conquest of disease. It includes all systematic study directed toward the develop- ment and use of scientific knowledge through fundamental research in the laboratory, clinical investigations, clinical trials, epidemiologi- cal studies, and engineering studies in (1) the causes, diagnosis, treat- ment, control, prevention of, and rehabilitation relating to, the physi- cal and mental diseases and other killing and crippling impairments of mankind; (2) the origin, nature, and solution of health problems not identifiable in terms of disease entities; (3) broad fields of science where the research is undertaken to obtain an understanding of processes affecting disease and human well-being; (4) research in nutritional prob- lems impairing, contributing to, or otherwise affecting optimum health; and (5) development of improved methods, techniques, and equipment for research, diagnosis, therapy, and rehabilitation. Medical and health-related research, hereafter referred to more briefly as "medical research," draws upon the life, physical, engineer- ing, psychological, and social sciences and upon many disciplines within each field. Trends in Manpower Engaged in Medical Research The number of professional workers engaged full or part-time in medical research rose from 19,200 in 1954 to 39,700 in 1960--a net in- crease averaging 3,500 per year (Table 1). The dominant characteristics of this growth are as follows: The largest increase has taken place in universities and research institutes. Dr. Rosenberg is the Chief, Resources Analysis Branch, Office of Program Planning, National Institutes of Health; and Mr. Stringham is the Director, Office of Program Analysis, Office of the Assistant Secretary (for Legisla- tion), U. S. Department of Health, Education, and Welfare. This article reproduces portions of the "Report on Manpower for Medical Research" pre- pared in response to a request by the Howse Appropriations Committee and appearing in Departments of Labor and Health, Education, and Welfare Appropriations for 1963, Hearings Before a Subcommittee..., House of Representatives, 87th Congress, Second Session, Part 4. This Report has been reissued as "Manpower for Medical Research Requirements and Resources, 1965-1970" (Resources for Medical Research, Report No. 3, January 1963), U. S. Department of Health, Education, and Welfare; Public Health Service, Publication No. 1001. Health, Education, and Welfare Indicators, July 1962 136 + The number engaged full-time in medical research has been rising, and those working part-time are devoting a larger share of their energies to research. + Research opportunities combined with teaching and/or service responsibilities have become increasingly attractive to M.D.'s. + Participation of Ph.D.-trained manpower has been rising rapidly, accompanied by the growing involvement of the physical and the social and behavioral sciences in medical research. + The underlying supportive force in this development has been the substantial enlargement of national programs for private and public support of research, research training, and construction of re- search facilities. In 1960, of the 39,700 professional workers engaged in medical research, 24,700 were employed in universities and research institutes, 7,800 in government, and 7,200 in industry. By field of specialization they were distributed as follows: biosciences, 17,160; clinical special- ties, 10,305; physical science, mathematics and engineering, 7,045; social and behavioral sciences, 3,255; dentistry, 610; and health pro- fessions and all other, 1,325. Table 1 Scientific and Professional Manpower Engaged in Medical and Health-Related Research . Increase 1954-1960 Time factor 195k 1958 1960 | Number Percent Total number 19,200 34, 600 39, 700 20, 500 106.8 Full-time equivalent (14,000) | (23,100) | (27,285)| (13,285) (94.9) Full-time 11,260 17,245 19,400 8,140 72.3 Full-time equivalent of part-time (2,740) | (5,855) | (7,885)| (5,145) (187.8) Part-time 7,940 17,355 20, 300 12,360 155.7 137 Increases in National Expenditures for Research and Development Since 1940 the Nation's total expenditures for research and develop- ment multiplied almost fifty-fold. The increase was particularly rapid be- tween 1950 and 1961, when expenditures grew from $2.9 billion to $16 billion. Research expenditures have increased at a more rapid rate than the gross falom product, rising from 0.34% percent of GNP in 1940 to 3.08 percent in 1961. RELATION OF TOTAL NATIONAL EXPENDITURES FOR RESEARCH AND DEVELOPMENT TO GROSS NATIONAL PRODUCT TRENDS IN TOTAL NATIONAL EXPENDITURES FOR PERFORMANCE OF RESEARCH AND DEVELOPMENT Billions Percent $20 T rrr TT v T ESLER EL Lao aaa 41a I ol A 0 Add A hdd A 1930 1940 1950 1960 1930 1940 1950 1960 Federal expenditures for research and development increased roughly $1 billion between 1940 and 1950. During the 1950's, however, the Federal outlay rose nearly seven-fold, jumping to $8.8 billion in 1961. Triggered by rising military research expenditures for national security and, more recently, by the Nation's space research activities, research and develop- ment expenditures have mounted from less than one percent of the Federal budget in 1940 to almost 3 percent in 1950 and to nearly ll percent in 1961. RELATION OF FEDERAL RESEARCH AND DEVELOPMENT EXPENDITURES TRENDS IN FEDERAL EXPENDITURES TO TOTAL BUDGET EXPENDITURES FOR RESEARCH AND DEVELOPMENT Billions Bian $10 9 0 1940 1945 1950 1955 1960 NOTE: Dota since 1983 reflect inclusion of research and development financed with funds formerly classified es procurement. 1950 19338 1960 0 1940 1945 138 Expenditures for Medical Research and Development Expenditures for medical research generally have followed the pattern of the Nation's total research effort. Total medical research expenditures, public and i rose from $148 million in 1950 to gbout $1 billion in 1961. Medical research expenditures now approxi- mete 6 percent of all expenditures for research and development (Table 2). Table 2 Medical Research and Development Expenditures Research and Development Medical (millions of dollars) as Year percent Total Medicsl of total 1950 2,900 148 3.1 1951 3,400 163 4.8 1952 3,800 173 4.6 1953 5,150 203 3.9 1954 5,620 225 4.0 1955 6,390 240 3.8 1956 8,460 285 3.4 1957 10,040 397 4.0 1958 11,160 490 4. h 1959 12,430 587 $7 1960 14,000 715% 5.1 1961 16,000 890% 5.6 Source: 1950-52, Department of Defense; 1953-60, National Science Foundation; 1961, National Institutes of Health. 1/ According to more recent data, the Nation's expenditures for medical research were some $820 million in 1960 and exceeded $1 billion in 1961. The revised estimates reflect better coverage of Federal expenditures and expenditures in the medical supply and medical electronics sectors of indus- try. As soon as possible, the basic series on the Nation's expenditures for medical research from 1947 forward will be adjusted to reflect the improvements in coverage. However, the estimates for 1960 and 1961 shown in the table have been used throughout this analysis in order to permit comparison with prior years. Federal support of medical research has become an increasingly significant component of the Nation's total medical research expenditures, rising from 32 percent in 1947 to 56 percent in 1961. Industry and other non-Federal sources also are supporting substantially expanded outlays, which reached $394 million in 1961. 139 Future Growth of Medical Research Expenditures Various study groups have considered possible future increases in expenditures for medical research, taking into account such factors as prior growth rates, anticipated increases in gross national product, total research and development as a percent of GNP, and medical research as a component of total research and development. Based on these factors, alternative projections of medical research expenditures to 1970 have been computed. These projections range from $2.3 billion to $3.3 billion (Chart 1). The total of $3 billion in national expenditures for medical research in 1970 has been widely accepted.* It has been used as a reasonable and feasible basis for estimating research manpower needs. Chart 1 NATIONAL EXPENDITURES FOR MEDICAL RESEARCH, 1947-1959 AND ALTERNATIVE PROJECTIONS, 1960-1970 Billions Billions TT TTT TT TTT] mt) 301 — - . v . } fromenfee a 1 ted] | ! wp siti APL i 28 | | } | | oToERATE | 23 20} TT, genr= | st! | | woh. — a gi IO is ie | Eo emer dre 1. o*” Se 1 a; 08f— ; : : : I 3 + eS 1 ] 06! - . , : - r 4 ” — TH 1 | oa} rt i - eee eb ch fe] 03 Ft 1 | et 3 02} - — Jee fees IS TE SES 0. 1947 1950 1955 1960 1961 1965 970 *The figure of $3 billion should not be construed as a goal or target of this Administration. Furthermore, the $3 billion projection is in terms of 1958 dollars and does not include any adjustment for erosion in the pur- chasing power of the dollar. Assuming continuation of the 1954-1958 rate of inflation, $3 billion in 1970 would purchase only $2.3 billion of re- search, expressed in 1958 dollars. Thus, if the 1954-58 rate of inflation continues through the 1960's, the $3 billion projection for 1970 may range between $4 billion and $4.8 billion when expressed in 1970 current dollars. 140 Manpower Needed to Meet the Future Growth of Medical Research Future manpower requirements for medical research may be estimated by dividing expenditures per professional worker into projected research expenditures. Between 1954 and 1960 expenditures per year per professional worker in medical research increased from about $12,000 to about $18,000. During the 1960's expenditures per professional worker will continue to rise, reflecting (1) large-scale clinical research programs which in- volve high costs per investigator, (2) more complex and precise instrumen- tation, (3) conduct of large-scale, long-term population studies, and (Lt) greater use of higher-paid and more highly skilled professional-level technicians. These increased costs will come about even if prices remain constant for the next decade. If it is assumed, however, that such forces will result in an 8 percent yearly increase in expenditures per professional worker (expressed in 1960 constant dollars), as compared with the 5.3 per- cent per year increase that prevailed during the period 1954-1960, expendi- tures per professional worker will be about $39,000 in 1970. By dividing the estimated national expenditures of $3 billion for medical research in 1970 by $39,000 per research worker, it is estimated that some 77,000 professional medical research workers will be needed in 1970. This requirement will call for adding 45,000 professional workers over the decade, including 7,700 needed for replacement due to death, re- tirement, and shifts to other activities among the present 39,700 persons engaged in medical research (Table 3). Thus the number of additional scientists--45,000--needed for medical research by 1970 exceeds the total number now at work. While the distribu- tion by performing sector, level of training, and field of science of the additional researchers can be predicted with less confidence, past trends indicate that the future probably will reflect: + A higher proportion of researchers working in universities, medical schools, hospitals, research institutes, and research organiza- tions in foreign countries. + A higher proportion of doctoral trained researchers. + A broader distribution among the fields of science partici- pating in and contributing to medical and health-related research. + Increasing specialization of the research function and rising recognition of research as a full-time socially useful career. + Rising needs in such rapidly growing disciplines as bio- physics, genetics, immunochemistry, biomathematics, and neurophysiology, with an attraction into these fields of biologists, physicists, chemists, mathematicians, and clinicians. 141 . Sharply rising requirements for well-trained, highly skilled technicians to complement the professional researchers, especially as complex instrumentation and precise controls become in- creasingly significant factors in medical research. Meeting Medical Research Manpower Requirements for the Future An illustrative distribution by level of training of the addi- tional 45 ,000 researchers needed by 1970 are presented in Table 3 and in Chart 2. Table 3 Medical Manpower Requirements for 1970 Less than Doctoral doctoral Item Total M.D. (M.8., M.P.H., D.D.8. | Ph.D. | M.A., B.S., Total | D.V.M. | Sc.D. | A.B.) Requirements for 1970 77,000 | 60,000 | 20,500 | 39,500 17,000 Less employment, 1960 39,700 | 29,400 | 11,400 | 18,000 10, 300 37,300 | 30,600 9,100 | 21,500 6, 700 Plus attrition through death, retirement, and movement into other activities 7,700 | 5,900 2,400 3,500 1,800 Equals net additional requirements, 1961- 1970 45,000 | 36,500 | 11,500 | 25,000 8,500 Chart 2 MANPOWER FOR MEDICAL AND HEALTH- RELATED RESEARCH BY DEGREE 1960-1970 NET ADDITIONAL JOAL REQUIREMENTS REQUIAEHENTS Less Than Doctoral Less Than Less Thon Doctoral Doctoral During the past ten years, private and public research and training programs have attracted increasing numbers of doctoral level investigators from all fields of science into medical research. These programs have (1) enlarged opportunities for research, (2) expanded and equipped greatly-needed research facilities, and (3) provided sup- port for research training and for the graduate education processes through mechanisms that have aided both students and institutions. All of the existing mechanisms must be retained and expanded, with suitable modifications, if the needed manpower is to be produced. Until the late 1960's, the supply of manpower for medical re- search will depend almost exclusively upon those who have already received M.D. or Ph.D. degrees, and who are now getting postdoctoral research training or experience. It is probable that about one-half of the additional Ph.D.-trained manpower and roughly two-thirds of the M.D.'s must come from the group already past the basic Ph.D. and M.D. training respectively. The remaining doctoral-trained researchers must come from those who have not yet received their advanced degrees. Here two factors are important--the total output of M.D.'s and Ph.D.'s in science, and the proportion of this total output engaging in medical research. So far as total output is concerned, it appears that about 75,000 new M.D.'s may be produced between 1960 and 1970. This estimate rests upon maintenance of the productivity of existing schools, full activation of schools already established, and completion of schools now firmly planned. It is also estimated that between 90,000 and 95,000 new Ph.D.'s may be produced between 1960 and 1970. Both of these forecasts rest upon the assumption that deliberate efforts to expand output will be made. The more successful the efforts, the larger the output. The figures further emphasize the fact that enlargement of the pool of M.D.'s and Ph.D.'s in science is fundamental to an expanded medical research effort. From the total pool available, those who can and will engage in medical research is somewhat problematical. In particular, the mounting demand for more scientists in other activities affecting the national interest will influence the realization of these estimates. In any event, however, it is clear that the required numbers will not be avail- able for research unless: 1. Research combined with teaching and/or service becomes an increasingly attractive and productive career pattern for M.D.'s, recognizing that most M.D.'s in research in medical schools and teach- ing hospitals will contribute to teaching and service, and 2. A steadily increasing proportion of Ph.D.'s in the biolog- ical and physical sciences, mathematics, engineering, psychology and the other social and behavioral sciences engage in medical research. 143 Chaxrt 3 POPULATION BASE FOR Ph.D. OUTPUT, 1930-1970 18 18 17 wn => 16 o ~ 15 = = 14 2 = 13 = 20-24 year-olds o Graduate Enroliment Base E12 I <« | 2 Ul ii | | a 25-29 year-olds Ph. D. Degree Base $ w 10 9 {9 1930 '35 '40 ‘45 '50 ‘55 '60 '65 ‘70 YEARS After 1970, the resource base for meeting medical research manpower requirements will broaden substantially through (1) a. sharp expansion in the population age groups from which new M.D.'s and Ph.D.'s must be drawn, (2) steeply rising enrollment at all levels of higher education. This base will expand most rapidly during the late 1960's and thereafter (Chart 3). The longer range population trends, reflecting the increased number of births that occurred during and after World War II,will create a wave of college students and subse- quently of advanced degree candidates that will affect the supply of new entrants into medical research, primarily after 1970. Additional measures directed primarily at expanding the total pool of manpower are needed, and efforts should be initiated as soon as possible to: * Expand college matriculation, especially among more talented, less privileged youth. + Enlarge graduate enrollment in all fields, but especially in fields most directly relevant to medical research. 14h + Increase the number of medical students as rapidly as possible to assure an adequate future supply of physicians to meet all the health needs of the Nation. + Accelerate the output of Ph.D.'s. + Orient the Nation's youth toward the exciting challenges and rewarding career opportunities in biology and medicine. Meeting the Nation's future requirements for medical research manpower, thus, will depend upon national policy and action at both the Federal and non-Federal levels designed to (1) provide more general support for the graduate education prozess, (2) reduce the attrition and accelerate the flow of graduate students toward the Ph.D. degree, (3) expand research and teaching facilities to accommodate steadily growing research activities and rapidly rising enrollment, (4) enlarge the Nation's capabilities for specialized and intensified research training at the post doctoral level, (5) develop an adequate supply of highly skilled, professional-level technicians, as well as technicians at lower levels, demanded to assist in increasingly complex, highly instrumented research activities, and (6) assure stable and rewarding career opportunities under conditions most suited to productive scien- tific inquiry. 145 HEALTH FACILITY CONSTRUCTION Jack C. Haldeman and Luther W. Stringham A wide variety of health and medical facilities provide care and treatment for persons with illnesses, injuries, or other conditions re- quiring medical attention. These facilities include: general hospitals, which are primarily for the short-term care of acute illnesses and in- juries and for obstetrics; mental hospitals; tuberculosis hospitals; chronic disease hospitals; nursing homes; diagnostic and treatment centers; public health centers; and rehabilitation facilities. National Expenditures for Construction The construction of hospitals and other medical facilities has fluctuated widely during the past three decades (Chart 1). During the depression years of the 1930's and during World War II construction was at a low level, averaging less than $100 million per year. Following the War it rose rapidly to a peak of over $900 million in 1951. After some decline in the mid-1950's, the current dollar value of hospital and medi- cal facilities construction since 1958 has approximated $1 billion per year. Chart 1 Health Facility Construction: Miliions oF Darsers Value Put in Place MiThene of Selanne hd 1200 Total in J N\ 1957-59 Dollars / J / / { I / | / Total in 1 60 || / Current Dollars / / AN 4 *° / Nr” S — —_ edd A eb—— A saosnk A A heeded edd 4 0 1935 1940 1945 1950 1955 1960 1965 Health, Education, and Welfase Treads Dr. Haldeman is the Chief, Division of Hospital and Medical Facilities, Public Health Service; and Mr. Stringham is the Director, Office of Program Analysis, Office of the Assistant Secretary (for Legislation), U. S. Department of Health, Education, and Welfare. This paper is based primarily on "The Hill-Burton Program: Accomplishments and Future Course," July 1962, Division of Hospital and Medical Facilities, Public Health Service, U. S. Department of Health, Education,_and Welfare. Health, Education, and Welfare Indicators, September 1962 146 Even when adjustment is made for increases in building costs, the yearly volume of construction since 1946 has been about three times the level of the period 1930-1945. Hospital Construction by Source of Funds During the 14 years 1948 through 1961, $10.3 billion were spent on the consgyuction of health facilities, excluding Federally-owned facilities. Of this total, $6.9 billion were spent on projects without Federal aid. The volume of construction without Federal aid, after reach- ing a postwar volume of about $500 million annually, has maintained this level on a fairly stable basis (Chart 2). In addition to the $6.9 billion spent on health facilities without Federal aid, $3.54 billion was spent from 1948-1961 on facilities for which Federal aid was received under the Federal hospital and medical facilities construction (Hill-Burton) program. Of these expenditures of $3.4 billion, the sponsor's share was $2.2 billion, and the Federal share was $1.2 billion. Thus Federal funds under the Hill- Burton program have accounted for 35 percent of the cost of Federally-aided construction and 12 percent of total hospital construction (other than direct Federal construction). To date, changes in Hill-Burton appropriations have had no demon- strable effect on the volume of construction without Federal, aid. Rather the variations in non-aided construction appear to be related more con- sistently (with a two-year lag) to changes in the cycle of business activity. Chart 2 Health Facility Construction by Millions of Dollars : . Millions of Dollars Y500 Type of Financing ape IN 4 1200 7 1200 Total Hospital Construction / No” / ~ / 900 AN 7 900 7 sey’ Nota IN / Non-Federel V4 3 f / 600 a Without Federal Aid 300 / Hill-Burton Sponsor's Share I~ 300 Hill-Burton Federal Sharg,.,..eeee py 0 1960 1965 Health, Education, sad Welfare Treads 1/ Direct Federal construction, mainly by the Armed Forces, Veterans Admin- istration, and the Public Health Service, totaled $1.1 billion during this period. 147 Genesis of the Hospital Survey and Construction Act Prior to 1946 hospital expansion in the United States was uneven. There was overbuilding in some communities and a complete lack of facili- ties in others. In 1928 some 1200 counties, with a population of 15 million, had no hospital facilities. With. the close of the War, growing demands for hospital care focused national concern on the need for increasing the supply of hospi- tal facilities. In August 1946, following intensive study by the Ameri- can Hospital Association, the Commission on Hospital Care, and the United States Public Health Service, Congress passed the Hospital Survey and Construction Act, establishing what is generally known as the Hill-Burton program. Its major purposes were twofold: (1) to assist the States in making an inventory of existing facilities, in surveying their needs for additional facilities, and in developing comprehensive plans for construc- tion of additional facilities; and (2) to provide the necessary incentive, through financial assistance to the States, for the construction of long- needed public and other nonprofit hospitals, public health centers, and related hospital facilities. In 1954 the Act was amended to provide funds for constructing nursing homes, diagnostic and treatment centers, rehabilitation facili- ties, and chronic disease hospitals. At the same time the Public Health Service was authorized to conduct and make grants for hospital research. The enactment of the Community Health Services and Facilities Act of 1961 further expanded the research program by authorizing experimental and demonstration construction and equipment projects. To participate, each State is required to designate a single State administering agency and to develop an annual State Plan for construction, including an inventory of all civilian inpatient and outpatient facili- ties available and a long-range program for meeting additional facility needs. Sums appropriated are allotted to the States in accordance with a statutory formula which takes into consideration the population and rela- tive per capita income of the States and territories. The formula oper- ates so that the largest per capita share of the Federal appropriation goes to the States with the lowest per capita income, which also are generally those having the greatest unmet need for hospital services. The States of lowest per capita income receive a per capita share of the annual Federal appropriation approximately four times as large as in the States with highest per capita income. The total minimum annual allot- ment to a State is now $550,000. Federal participation may range from one-third to two-thirds of the total costs of constructing and equipping an approved project. 148 Summary of Accomplishments Under the Hill-Burton Program As of June 30, 1962, a total of 6,236 projects had been approved for Federal aid under the Hill-Burton program. Of this total, 4,728 were completed and in operation. The remaining 1,508 are under construction or in the planning stage. The 6,236 projects will provide 274,205 inpatient beds and 1,6 other health facilities, as shown below: 206,074 general hospital beds 17,553 mental hospital beds 31,325 nursing home beds 12,04h chronic disease hospital beds 7,209 tuberculosis hospital beds 905 public health centers 478 diagnostic and treatment centers 234 rehabilitation facilities 27 State health laboratories Thus since World War IL important progress has been made in pro- viding for health facilities construction from both private and govern- mental sources. Additional hospital beds and health centers have been provided, and there also has occurred, mainly as a result of the Hill- Burton program, (1) systematic statewide planning for hospital facilities; (2) development of standards of need; (3) achievement of better distribu- tion of facilities; (4) improvement of hospital design; (5) improvement in hospital operation; (6) effective cooperation between government and voluntary health agencies; (7) improvement of medical care in low income States and in rural areas; and (8) aid to teaching centers for training physicians and nurses. Despite progress in construction and in Statewide planning, wide gaps and imbalances still exist in the availability of hospital and related health facilities. New problems, which must be faced and solved, accent the need for more intensive, systematic, and sound planning at the community level. Remaining needs and construction objectives for the future are summarized below. General Hospitals National progress in construction has been substantial, but uneven, during the past 15 years. Marked gains have been made in general hospital facilities, particularly in low-income States, in the smaller towns and rural areas. Nationally, the number of acceptable general hospital beds has increased from 388,100 in 1948 to 632,400 in 1962--a bed rate increase per thousand population from 2.8 to 3.5. Nevertheless, in many areas, acceptable general hospital facilities are unevenly distributed or lacking. Serious shortages exist in many 149 fast-growing suburbs, in sections of metropolitan areas occupied princi- pally by minority groups, and in some sparsely-settled rural areas. In contrast, excess general beds and a consequent unnecessary duplication of services are found in some communities or portions of communities. Continuing population growth, migration from rural to urban areas, move- ment from urban centers to suburban communities, and urban renewal pro- grams are major factors in adding to the problem of the distribution of facilities. In planning to overcome shortages and maldistribution of facili- ties, the impact of other factors must be weighed; for example, the availability of alternative types of facilities such as skilled nursing homes, the introduction of home care prograums, provisions for ambula- tory care, or the extension of general hospital functions into areas such as psychiatric or rehabilitation service. Long-term Care Facilities Recent substantial gains have been made in the provision of chronic disease and nursing home (long-term care) facilities for the elderly. Since 1957 the number of acceptable long-term care beds has increased by 65 percent--from 155,500 to 255,900. Although it is difficult to estab- lish precise need figures, the States estimate that less than one-third of their long-term bed need has been met and that an additional 500,000 beds are needed. This estimate is confirmed if the long-term care beds in all States were brought up to the level of the five States with the highest ratios of long-term care beds per 1,000 elderly. Gross as are the present inadequacies in long-term care facilities, the future outlook is for even more serious deficiencies unless rigorous action is taken. In 1960 the population aged 65 and older numbered nearly 17 million. By 1980 the elderly probably will exceed 24 million. Special effort is needed, not only to correct present deficiencies, but also to prevent the gap between existing and needed facilities from widening as the numbers of aged increase. Moreover, the possibility of passage of Federal legislation that will partially remove the economic barrier to institutional care of the elderly further emphasizes the need for early and aggressive action in meeting the need for long-term care facilities. Mental Health Facilities Although acceptable mental beds have steadily increased in number over the years, they have failed to keep pace with population growth. Between 1948 and 1962, the acceptable mental bed capacity increased from 380,000 to 468,000, but in terms of beds per 1,000 population, dropped from 2.75 beds per 1,000 persons to 2.60. In the past, additional needs for mental facilities have been met by expanding existing State and local government institutiens. Current planning concepts discourage further construction or expansion of large mental institutions and emphasize the need for providing smaller, flexible, community-based facilities. The 150 wide spectrum of services to be provided through community-based mental health facilities would include activities such as outpatient and emer- gency care through hospitals or mental health centers, increased use of general hospitals for treatment of psychiatric patients, halfway houses, day and night hospitals, and nursing homes. The majority of States estimate their need for mental beds on a fixed bed-population ratio--usually 5 beds per 1,000 persons. On this basis, the present existing acceptable bed count constitutes only about 50 percent of the estimated national need. While the precision and validity of this programming technique is open to question, the crowded conditions of mental hospitals and the need for changing to community- based facilities attest to the need for additional construction activity in this area. Studies are now underway to determine the scope of the mental illness problem and the numbers and types of facilities required to provide needed care. Facilities for the Mentally Retarded Approximately 5 million persons, or about 3 percent of the total population, are estimated to be mentally retarded. Nearly one-third are under 20 years of age. Traditionally, State institutions have sought to provide care, treatment, training, and education for retarded individuals, elther in preparation for return to the community or as the basis for a contented and useful life within the institution. The trend today, how- ever, is toward caring for as many of the mentally retarded as possible outside of institutions. The mildly retarded seldom require institutional care. However, a greater number of the moderately retarded and almost all of the severely retarded ultimately require care in a facility that provides not only educational and training programs but also medical treat- ment for complicating physical problems. It is essential that careful consideration be given to the treat- ment and protection of retarded individuals on the basis of individual need. Programs should be planned for a wide range of deficiency, includ- ing lifetime care for some. Although institutions for prolonged care must be basically hospitals, other kinds of community facilities and training and rehabilitation programs should be established for the moder- ately and mildly retarded. These include day care centers, sheltered workshops, diagnostic and evaluation centers, nursing homes, foster care and homemaker services, and special classes within the educational system. Tuberculosis Hospitals Nationally, the need for tuberculosis facilities is continuing to decline with the decreasing incidence of new cases requiring institu- tional treatment. Within the past decade, more than 200 tuberculosis hospitals have closed their doors or have converted to other uses. Low occupancy rates and rising operating costs, combined with pressures to make excess beds available for other conditions, have been major factors in decisions to close or convert tuberculosis facilities. Although new 151 construction has virtually ceased, the problem of effective use of exist- ing facilities remains to be solved. Not to be overlooked is the exten- sive modernization and renovation needed for those facilities which con- tinue in use--many of which were established in the early 1900's. As in the mental illness field, trends in the treatment and care of the tuberculous have moved toward greater emphasis on early diagnosis and ambulatory care. Plans for needed new construction of tuberculosis facilities should be made in conjunction with plans for other chronic care facilities, including the provision of service through specialized units of community-based general hospitals. Modernization or Replacement of Older Facilities The depression years and wartime military restrictions caused cumulative deficits in hospital facilities. These deficits led to post- war emphasis on new hospital construction and plant expansion. Since most earlier hospitals were in urban centers, postwar attention with Federal assistance was focused on rural shortages, leaving urban projects with low priorities. Meanwhile, physical deterioration and functional obsolescence moved slowly but inevitably upon the older city hospitals. In many urban situations the problem has been intensified by population movement from the urban center to the suburbs, by industrial, commercial, and transportation changes, and by urban redevelopment programs. A Public Health Service survey in 1960 produced a national cost estimate of $3.6 billion to modernize or replace obsolete general and mental facilities without adding more beds. This estimate is nearly 4 times the current level of annual construction expenditures for hospi- tal and related facilities, including new construction as well as moderni- zation. The problem is particularly grave in many metropolitan areas where hospitals have been unable to replace worn-out buildings and equip- ment. The 1960 survey indicated a cost of $2.2 billion solely to modern- ize or replace general hospital facilities in metropolitan communities. Nevertheless, regardless of size of community, any hospital which has been in existence for a number of years may find itself in need of a capital construction program. Other Health Facilities The growing costs of inpatient care have led to greater utiliza- tion of ambulatory facilities for patients who formerly would have been hospitalized. Today, diagnostic and therapeutic services are offered by a variety of facilities, including hospital outpatient departments, diagnostic and treatment centers, public health centers, and rehabilita- tion facilities, as well as in offices of private physicians. Within a short span of years, facilities for ambulatory care have expanded substantially in number and volume of service provided. For example, between 1956 and 1962, the number of acceptable diagnostic and treatment centers in organized clinics or hospital outpatient departments 152 increased from 2,922 to 4,441. Between 1954 and 1958, visits to organized hospital outpatient departments increased by 30 percent and emergency visits by 81 percent. The public health center today offers a broad range of preventive health services including: control of communicable disease; public health nursing; sanitary engineering; maternal and child health clinics; immuni- zation clinics; dental health programs; health education; milk, food, and water inspection; school health services; and visiting nurse services. Between 1948 and 1962, the number of primary public health centers in- creased from 479 to 1,213. Auxiliary centers, which include publicly- owned laboratories and special clinics, increased from 723 to 1,020 over the same period. Rehabilitation centers have grown rapidly in number since World War II--evidence of" increasing public awareness that the handicapped should be restored to the fullest physical, mental, social, vocational, and economic usefulness of which they are capable. An estimated 2.2 million handicapped people of working age could benefit from vocational rehabilitation to enable them to work in the com- petitive market, in sheltered workshops, or at home. An additional 270,000 persons, it is also estimated, enter this vocationally handicapped group each year. Today, some 200 rehabilitation centers provide compre- hensive, coordinated services,--medical, psychological, social, and vocational--for the long-term or permanently disabled. In addition, hundreds of other facilities and agencies, including general hospitals, treatment centers, nursing homes, insurance companies, churches, labor unions, and fraternal orders, offer or support direct services for the handicapped. Nevertheless, there remains a serious need for additional facilities and services. Some large geographical areas with high density population lack suitable facilities and services. Many disabilities have only limited coverage. Frequently, services are inadequate in extent and in maintenance of quality. Development of needed facilities and services requires sound planning in coordination with that for other health programs. Medical Education Facilities Within the past decade, the supply of physicians in the United States have barely kept pace with population growth. Moreover, the number of applicants to medical schools has started to decline. Mean- while, the demand for medical service by the public has steadily increased. These trends, combined with continuing emphasis on research in all areas of medicine and medical practice, have greatly intensified the need for more physicians and medical scientists. Pending legislation proposes a lO-year program to relieve critical shortages of professional health personnel. The proposal includes provi- sion of grants to assist in new construction, replacement or rehabilita- tion of teaching facilities for training medical, dental, and other health personnel; a 5-year program of loans for students of medicine, dentistry, 153 and osteopathy; and a 3-year extension of the health research facilities construction program. A recent Public Health Service Report, "Medical School Facilities: Planning Considerations and Architectural Guide," provides guidelines for those contemplating the institution of new medi- cal schools and the planning of facilities. Nursing Education Facilities Numerous studies have documented the need for an increased supply of all types of nurses. It is estimated that graduations from professional schools of nursing should increase by 50 percent in order to satisfy the Nation's need for nursing service by 1970. Expansion of schools for practical nursing is also needed. Not only must new schools be estab- lished, but existing schools must add classrooms, faculty offices, and housing to increase their enrollments. To avoid duplication of costly educational facilities and to assure sound planning, the Public Health Service proposes to develop and publish a guide for colleges, universities, hospitals, communities and regional groups for planning nursing educational facilities. No current guidelines of this nature are available. Medical Group Practice Facilities The problem of effective use of health personnel is probably as important as the problem of increasing their numbers. Numerous advantages of combining the skills of general practitioners and specialists in a group practice arrangement have been demonstrated, including: improvements in the quality of care provided; economies to practitioners and patients alike; more effective utilization of health personnel; and stimulation of voluntary prepayment plans which offer comprehensive health services. A major obstacle to the development of group practice has been the costs involved in constructing the needed facilities and in providing essential services and equipment. Although loans from private sources may be available in some communities, and loans to profit-making group practice units are available from the Small Business Administration, such loans are generally for short durations, at relatively high interest rates, and require a substantial investment by the sponsoring group. Research Needs Research in the effective and efficient use of hospitals and the ways and means of adapting medical and technological changes to patient care has been sporadic and unorganized. Beyond a limited number of studies by foundations, associations and universities, and only in recent years by the Public Health Service, each hospital has attempted to meet its problems alone. All told, probably little more than $10 million is now spent annually in the area of hospital research. Modern medical care concepts and practices demand intensified hospital research efforts in areas such as: improved techniques for 154 determining facility and service needs; functional design of the hospital structure; hospital operating efficiency; hospital organizational patterns; coordination of community facilities with emphasis on the hospital as the focal point of a coordinated community-wide health program; and extension of the hospital into the home through organized home care programs. Summary of National Goals In summary, the goals for the future in health facility construc- tion should be to: 1. Increase substantially the capacity of acceptable facilities for long-term care, i.e., chronic care hospitals .and skilled nursing homes; 2. Increase construction of community-oriented mental health facilities; 3. Encourage construction, expansion, and modernization of facilities for the mentally retarded; 4. Support replacement and modernization of older hospitals; 5. Stimulate community planning for redistribution of facilities in metropolitan areas to achieve balanced urban hospital resources; 6. Develop an integrated program of construction and services for all types of facilities within an urban area, according to a community plan; T- Encourage construction of general hospitals in those remaining general hospital service areas with demonstrated shortages; 8. Provide for enough construction of all types of in- patient facilities to reduce present shortages and keep up with popula- tion growth; 9. Continue the construction of necessary public health centers and other outpatient facilities to improve preventive and ambulatory care; 10. Support new construction, replacement or rehabilitation of teaching facilities for training medical, dental, and other health personnel. 11. Expand research in support of (a) efficiency of design and operation of facilities and effective use of personnel; (b) the application of new medical discoveries in diagnosis and treatment to reduce the need for inpatient care; and (ec) improved organization of community machinery for continuity of care for patients, between the hospital and related institutions. 155 HOSPITAL COSTS, 1946-1961 Eugenia Sullivan and Earl E. Huyck Average hospital expense per patient day in the United States in 1961 rose to about $35--nearly four times the expense in 1946. The increase over 1960 was 8.5 percent and the annual dollar increase was the largest since 1946. Hospital expense per patient day is an aggregate figure derived by dividing total expenses (including outpatient expenses) by the number of adult inpatient days. Not included in total expenses are those expenses incurred by inpatients but not billed by the hospital, such as the cost of medical and surgical services rendered by the patient's physician. There are two sources of data that reflect changes in the cost of hospital services. One of these is the series on average hospital expense per patient day, which is computed by the American Hospital Association based on annual surveys of all hospitals accepted for listing by the Asso- ciation. The other is a series on hospital daily service charges developed by the Bureau of Labor Statistics, U.S. Department of Labor, in connection with the compilation of the Consumer Price Index. Dollars HOSPITAL EXPENSE PER PATIENT DAY 5 3 # 20 — 20 10 — 10 0 N | i | . | ’ | ‘ 1 i 1 0 1946 1951 1956 1961 Source: American Hospital Association Since 1946, according to the American Hospital Association, total expense per patient day in non-Federal short-term general and special hospitals* has increased by 273 percent. The total expense per patient stay increased by 213 percent from $86 to $267 between 1946 and 1961, even though the average length of stay decreased by 16 percent in the interim Miss Sullivan is a Staff Assistant and Dr. Huyck is a Program Analysis Officer in the Office of the Assistant Secretary (for Legislation); U.S. Department of Health, Education, and Welfare. For further information see: (1) American Hospital Association, Hospitals, Part II of Guide Issue, August 1962; and (2) Ethel D. Hoover, Bureau of Labor Statistics, U.S. Department of Labor, "Outlook for Medical Costs in 1962." *Includes all types of hospitals other than mental and tuberculosis. Health, Education, and Welfare Indicators, January 1963 156 A number of factors have contributed to the rapid rise in hospital costs--a rise much sharper than the cost of living in the postwar period. Improved medical technology, including new and expensive drugs and equip- ment and new medical techniques such as openheart surgery, has raised the cost of hospital care. The most important factor, however, has been the increased payroll expense, which accounted for 62 percent of the total expense of hospital operation in 1961. The payroll expense in short-term hospitals increased by 521 percent between 1946 and 1961. Historically the pay scales of hospital employees have been con- siderably below those of other workers. The continuing upward adjustment in hospital pay rates, including the substitution of cash payments for fringe benefits and reduction in the workweek, have been major elements in the considerable rise in payroll expense. The increase in hospital utilization and the usage of complex technical services that hospitals now provide have necessitated increases in the number of employees, and particularly of higher-salaried technical and professional employees. Percentages Increases in Hospital Costs for Short-term General and Other Special Hospitals American Hospital Association Indexes 1946 1961 Coron) Average length of stay (in days) 9.1 7.6 -16 Total expense Per patient day $9.39. $34.98 273 Per patient stays! | $85.57 $267.37 213 Number of employees (full-time euivaleit Number (in thousands) 505 1,149 128 Per 100 patients 148 235 59 Payroll expense Total (in millions) $619 $3,848 521. Percent of total expense 53 62 16 Average payroll expense per employee $1,226 $3,349 173 1/ Total expense divided by the number of adult inpatient days. 2/ Total expense divided by the number of adult inpatient admissions. 3/ Includes full-time personnel plus full-time equivalents of part-time personnel. Excludes residents, interns, and students. As operating costs have increased, hospitals have had to pass on most of the increase to consumers in the form of higher hospital daily service charges. Since 1946 hospital daily service charges have risen 228 percent--over four times as much as the Consumer Price Index for all items. The hospital daily service charge is the charge to full-pay adult inpatients for routine nursing care, room and board, and minor medical and surgical supplies. The daily service charge usually excludes the costs of laboratory work, X-rays, operating room, and special nursing, which are additional charges on the hospital bill. 157 According to the Bureau of Labor Statistics, hospital daily service charges for a semi-private room in 20 large cities in the United States in 1961 averaged $23.08, but ranged from a low of $14.52 in Houston to a high of $33.33 (including hospitals charging flat rate for all services) in Cleveland. The BLS figures are based on data collected primarily for calculation of the Consumer Price Index and are not adjusted for compara- bility; the cost differences among cities may be due to variation in quality of the services priced. Percentage Increases in Prices . for All Consumer Items and for Hospital Services Bureau of Labor Statistics 1946 1961 Increase Consumer Price Index (1957-59 100) (percent) All items 68.0 104.2 53 Medical 60.7 111.3 83 Hospital daily service charge 37.0 121.3 228 Semi-private room $7.13 $23.08 zl Over the whole postwar period (1946-61), prices for medical care increased more rapidly than the Consumer Price Index for all items combined- about 83 percent for medical care as compared with 53 percent for all items. The most distinctive characteristic in the movement of medical care prices has been the relatively slow but continuous upward movement. Of the 180 monthly changes from January 1947 through December 1961, the medical index went up on 168 separate occasions, remained stationary nine times, and decreased only three. The increases for medical care corresponded very closely with the steady upward trend for all services until the last few years when medical care prices rose at a somewhat faster pace. Throughout the past 15 years, however, hospital daily service charges have risen more rapidly than medical care prices generally. 158 HOSPITAL INSURANCE AND PROPORTION OF BILL PAID BY INSURANCE Augustine Gentile and Earl E. Huyck HOSPITAL INSURANCE COVERAGE Two-thirds of the civilian non-institutional population of the United States was covered by some form of hospital insurance in the latter half of 1959. The proportion of the population covered by hospital insurance was generally highest in the Northeast and North Central regions and lowest in the South. The proportion covered in the West was between the extremes and somewhat below the national average. Hospital insurance was held by 72 percent of the population in urban areas as compared with 68 percent in rural-nonfarm areas and 45 percent in farm areas. Persons in the age range in which the working population is concentrated (25-64) were more likely to have health insurance than children or old people. Among persons age 65 and older, approximately 46 percent were covered by some form of hospital insurance. In families where the income during the previous 12 months was under $2,000, approximately 33 percent of the persons had hospital insurance. But in fami- lies with the highest income, $7,000 or more, 84 percent had such insurance. PROPORTION OF HOSPITAL BILL PAID BY INSURANCE Among all patients discharged from short-stay hospitals in the two-year period July 1958 through June 1960, 68 percent had some portion of the hospital bill paid by insurance, and 51 percent had three-fourths or more of the bill paid. About three out of four persons who reported some insurance payment had 75 per- cent or more of the bill paid. Geographic Region The proportion of discharges for which some part of the bill was paid by insurance was higher in the Northeast and North Central regions (7h percent) than in the South (64 percent) or West (56 percent). Mr. Gentile is a Statistician in the Health Interview Survey Branch, National Center for Health Statistics; and Dr. Huyck is a Program Analvsis Officer in the Office of the Assistant Secretary (for Legislation), U.S. Department of Health, Education, and Welfare. The facts set forth in this digest are from two recent Health Statistics publications of the Public Health Service, U. S. National Health Survey: (1) Interim Report on Health Insurance, PHS Pub. No. 584-B-26, December 1960, based on 19,000 nationwide household interviews con- ducted during the period July-December 1959; and (2) Proportion of Hospital Bill Paid by Insurance, Patients Discharged from Short-stay Hospitals, PHS Pub. No. 564-B-30, November 1961, based on 75,000 household interviews from July 1958 through June 1960. Health, Education, and Welfare Indicators, February 1963 159 Race About Tl percent of white persons discharged from hospitals had some portion of the bill paid by insurance. For nonwhite persons the rate was 42 percent. CHARACTERISTICS OF PERSONS WHO HAD PART OR ALL OF HOSPITAL BILL PATD BY INSURANCE Urban Rural nonfarm ==] Rural farm 80 |— — 724 714 » 69.5 69.3 67.9 68.1 — 54.6 PERCENT I 401— — Both Sexes Male SEX Female Percent of hospital discharges with some insurance pay- ment for the hospital bill by sex and residence Age and Sex Between 70 and 80 percent of persons below age 65 (with the exception of the age group (15-24%) had some portion of their hospital bill paid by in- surance. Of persons 65 years and over, about 53 percent of men and 49 percent of women had some part of the bill paid. After age 65 the proportion of hospital discharges with some insurance payment dropped sharply, from about 63 percent for both men and women age 65- 69 down to 39 percent for men and 36 percent for women age 5 or over. 160 00 PERCENT 20 Urban-Rural Residence The proportion of hospital discharges for which some part of the bill was paid by insurance was about the same for residents of urban and rural non-farm areas (69 percent). However, the rate for residents of rural farm areas was much lower (55 percent). Male —ome=e Female — serrasesaes Female (excluding deliveries) Percent of hospital discharges with some insurance pay- ment for the hospital bill by sex and age. hospital bill paid by insurance. Percent of Persons discharged from short-stay hospitals who had insurance payments for the hospital bill Total discharges Percent of discharges Percent Percent with any Sex and age with any [with 3/4 or [insurance pay- insurance more of yg Sha bag . payment bill paid by or More o for the bill | insurance the bill paid by insurance Both sexes All ageS~-<-creccccmcmmccmccecaea 68.0 51.3 75.4 Under 15-=emcoccmcccc mmm mcmmmccccceeco 72.1 58.3 80.9 15-bimmmmmmmmm mm mm mmm mmm mmm mmm mmm mmm 66.9 50.6 75.6 U5 Bimmer mms wn 76.0 58.0 76.3 GB sma —————————————————— 51.2 30.3 59.2 Male All ageS--~c-cccmcomccccccmccaeceaes 70.6 55.7 78.9 Under 15--=mmmmmmmmemcommc ccc mmmmee 70.7 57.0 80.6 1S whl mmm mmm 0 sere mmm 74.7 62.2 83.3 US Bly smi ————————————————— 75.5 59.1 78.3 654mm mmm mmm mmm mmm mmm mmm meee 53.1 33.4 62.9 Female All ageS-=--==cmcocmcmcceeaaes 66.4 48.7 73.3 TE ET ——— 73.9 59.9 81.1 LN ———— 64.5 47.1 73.0 Ge Linn wmmmmsmmimmm mn vm en 76.4 56.9 74.5 ET hn se sme mr mmm ———————————— 49.3 27.3 55.4 Work 16 About 79 percent of all persons who "usually work" had some part of the Persons age 65 and over who "usually work" had about the same proportion (80 percent) of hospital discharges with some insurance payment of the bill as did younger "usually working" persons. Nearly one-half (45 percent) of "retired" persons age 65 and over had some portion of the bill paid by insurance. Income The higher the family income, the larger the proportion of discharges for which some part of the hospital bill was paid by insurance. In families with incomes under $2,000 a year, two-fifths of the persons discharged reported that at least some part of the hospital bill had been paid by insurance. The rate increased from 59 percent for the $2,000-$3,999 group to 79 percent for the $4,000-$6,999 group and to 81 percent for the $7,000 and over group. However, for persons age 65 and over whose annual income was $7,000 or more the proportion of discharges for which some part of the hospital bill was paid by insurance {51 percent) was the same as that for all income groups age 65 or over. Percent of discharges with some insurance payment for the hospital bill by annual family income Family income Sex and age All Under | $2,000- | $4,000- 00 ki incomes | $2,000 | 3.999 | 6.999 $7,000+. Unknow Percent Both sexes All agesS-~--==-cemme-eecaa- 68.0 39.6 59.2 79.0 81.0 58.8 Under 15--------cocceccmmccccnaa= 72.1 32.9 59.4 81.1 80.4 71.9 15-44=mmmccmcccccccceccncncancn—- 66.9 33.0 54.7 78.0 81.3 51.2 45-64=mmcmccmceccc ccc cma 76.0 50.1 71.7 83.8 89.0 69. 65t==-mmeeccccccc ecm cencnnaae 51.2 42.7 59.8 63.5 51.1 45.6 Male All ages---=====c-cecem—co-- 70.6 41.2 62.8 81.7 83.3 64.1 Under 15----=---c-ccecccocencnao= 70.7 31.1 56.4 79.3 83.6 68.5 15-44=nmcccccccccnnccccncannnnnn- 74.7 45.2 63.0 85.0 85.7 63.8 45-64-==-ccmmceccnccm nnn a me 75.5 45.8 69.6 84.5 87.6 66.5 (EEL EL EL DE EEL El 53.1 39.5 62.2 65.7 58.0 54.1 Female All agesS~-~-~--c-cmcmnea—a—- 66.4 38.6 57.1 77.5 79.5 56.1 Under 15----ccccccccccccnncaana—- 73.9 35.5 63.3 83.2 77.0 75.5 15-bfmmemmmmccccc cece cme 64.5 29.3 52.0 75.9 79.8 47 .4 45-64=-mmememccccm mcm mmc mmm ae 76.4 53.4 73.7 83.2 90.7 71.0 65H ~emmmmmmmemememmmec———ccee———— 49.3 45.8 56.8 61.0 42.5 40.1 PART III CURRENT AND EMERGING ISSUES AND OPPORTUNITIES Education 163 16k EDUCATIONAL ENROLLMENTS, 1962-63 Kenneth A. Simon Total for the School Year Enrollment in the Nation's public and private schools from kindergarten through college, increasing for the 18th consecutive year, will reach a new all- time high of 51.3 million in the 50 States and the District of Columbis in the school year 1962-63. This is an increase of 2.0 million over the enrollment of 49.3 million for the 1961-62 school year. Elementary and Secondary Schools Anticipated enrollments in public and nonpublic schools from kindergarten through Grade 8 are estimated at 35.0 million, an increase of 800,000. In Grades 9 through 12, the increase is expected to be 900,000--from 10.8 to 11.7 million. Rising enrollments in kindergarten and elementary and secondary schools are due chiefly to the increased number of births since 1946. An estimated 1,Th4,000 classroom teachers will be needed by the public and nonpublic elementary and secondary schools, 3.6 percent more than the 1,684,000 employed in 1961-62. Higher Education In institutions of higher education, both public and private, an enroll- ment increase of 300,000--from 4.3 to 4.6 million--is anticipated. So far the steadily mounting college enrollments have resulted largely from the growing interest in attending college. Part of the increase in enroll- ments since 1959, however, is attributable to increases in births during the years 1940-43. Enrollments will increase substantially commencing about 1965 as the postwar children begin to reach college age. Supporting Tabulations On the following two pages are tabulations of total enrollments by level and higher education degree credit enrollments by States. Dr. Simon is the Chief of the Reference, Estimates, and Projections Section; Office of Education, U. S. Department of Health, Education, and Welfare. The enrollment estimates presented here are for the entire school year, as con- trasted with opening (fall) enrollment data. Health, Education, and Welfare Indicators, September 1962 165 Estimated Total Educational Enrollments, 1961-62 and 1962-63¥ School Year Enrollments (millions) Grade Level and Type of School 1961-62 1965-63 Total, elementary, secondary, and higher education..... . 49.3 51.3 Kindergarten through Grade 12 Public school system (regular full-time)........ 38.2 39.7 Nonpublic schopls (regular full-time)........... 6.5 6.7 Other schools. .cee.veeeeennnn VERE SEERA ey + .3 Total Kindergarten through Grade 12....... ’ ¥5.0 46.7 Kindergarten through Grade 8 Public school system (regular full-time)...... as 28.7 29.4 Nonpublic schopls (regular full-time)......... on 5.5 5.4 Other schools®........ SEARS LENSE sE NABER E ISIN .2 we Total Kindergarten through Grade 8......... 34.2 35.0 Grades 9 through 12 Public School System (regular full-time)........ 9.5 10.3 Nonpublic schopls (regular Ll Ll~bime) ens sonus ew 2 1.3 Other sSch00ls.ecceeccessccccencesscsscscscscsccnse me - Total Grades 9 through 12.............. "onion = oO o¢] ju = —d Higher Education Universities, colleges, professional schools, junior colleges, normal schools, and teachers colleges (degree-credit enrollment)........... 4.3 4.6 1 The estimates for 1962-63 reflect fall 1961 enrollment statistics and are derived from the increase expected from population changes combined with the long-run trend in school enrollment rates of the population. Nonpublic elementary and secondary school data are based on a sample survey. 2/ Includes Federal schools for Indians, Federally-operated elementary-secondary schools on posts, model and practice schools in teacher training institutions, subcollegiate departments of colleges, and residential schools for exceptional children. 166 Higher Education Degree Credit Enrollment, Fall 1961 Total Full-Time Part-Time State Percent of Percent of Percent of Number U.S. Total Number 0.85. Pokal Number U.S. Total UNITED STATESZ (50 states and D.C.) 3,860,643 100.00 2,713,901 100.00 1,146,742 200.00 Lobes. vows ne vem 47,967 1.24 39,011 1.44 8,956 0.78 ALBska. ovo vem ne 2,990 0.08 827 0.03 2,163 0.19 ATLZONR: vs unm svws 38,239 0.99 23,755 0.88 1h, 484 1.26 ATRBNBOE + 5 5 sivnin wnni 27,719 0.72 23,742 0.87 3,977 0.35 CaliLomida. : »omnvnms 499,505 12.95 277,388 10.23 222,117 19.37 Coloradt:c eqs revees hg, 707 1.29 43,244 1.59 6,463 0.56 Connecticut. ........ 55,319 1.43 35,070 1.29 20,249 L=77 Delaware.....o...... 8,002 0.21 5,002 0.18 3,000 0.26 District of Columbia 46,895 1.21 22,874 0.84 24,021 2.09 Florida. -...veenunnn 79,660 2.06 57,121 2.10 22,539 1.97 Georgla.....ovuunnns 51,955 1.35 Ll 26k 1.63 7,691 0.67 Howell cosine vor suns 11,697 0.30 8,488 0.3L 3,209 0.28 aap usin vs gees 12,412 0.32 10,156 0.37 2,256 0.20 IIlinolsies vussussss 216,577 5.61 136,211 5.02 80, 366 7.01 Tndleng, ovenviuv ss 105,294 2.73 82,839 3.05 22,455 1.96 Toueonvvconimning » 61,154 1.59 53,088 1.96 8,066 0.70 Bansag. «osossmusii 56,148 1.45 bly, 565 1.6k4 11,583 1.01 KenGuehy nmin iam 51,784 1.34 38,232 1.41 13,552 1.18 Louisiana........... 62,312 1.61 50, THO 1.87 11,572 1.01 Maine............... 13,687 0.35 11,671 0.43 2,010 0.18 Maryland. ........... 59,931 1.55 36,262 1.34 23,669 2.06 Massachusetts. ...... 138,167 3.58 103,271 3.81 34,896 3.04 Michigan............ 169,822 k.ho 115,451 Lk. 25 Sh, 371 L.75 Minnesota. .......... 83,174 2.15 66, 42k 2.45 16,750 1.46 Mississippi......... 38,572 1.00 35,492 1.31 3,080 0.27 Miowourd cassvsssasns 88,790 2.30 67,846 2.50 20,944 1.83 Monbang. . csoessnsnns 13,869 0.36 12,576 0.46 1,293 0:11 Nebraska. coosssosns 33,434 0.87 25,824 0.95 7,610 0.66 Nevada........ cv... 4,738 0.12 2,897 0.1L 1,841 0.16 New Hampshire....... 13,624 0.35 11,342 0.42 2,282 0.20 New Jersey.......... 92,727 2.40 51,503 1.90 41,20h 3.59 New Mexico....uv.... 19,253 0.50 12,671 0.47 6,582 0.57 New York .covsveeveen 370,619 9.61 215,398 7495 135,221 13.54 North Carolina...... 77,481 2.01 67,109 2.47 10,372 0.90 North Dakota........ 14,201 0.37 13,091 0.48 3,110 0.10 ORIG wm minamsma nasi 188,016 4.87 130,729 4.32 57,287 5.00 OLahoma. vo avanio enon 59,623 1.54 48,710 1.79 10,913 0.95 OFSgOf sii mvs mmm on b7,786 1.24 35,406 1.30 12,380 1.08 Pennsylvania........ 204,401 5.29 150,256 5.54 Sh, 145 5.72 Rhode Island........ 19,842: 0.51. 1h, 7h 0.54 5,101 0.hk South Carolina...... 32,749 0.85 28,814 1.06 3,935 0.34 South Dakota........ 15,270 0.40 12,687 0.47 2,583 0.23 Tennessee........... 6h, 579 1.67 55s T75 2.06 8, 80k 0.77 DORA te 0nnon enamine 198, 784 5.15 145,549 5.36 53,235 4.64 Ss oe vv vs wns minin 35,54 0.92 29,437 1.08 6,137 0.54 Vermont...eoevuuun.n. 10,053 0.26 9,649 0.36 Lok 0.04 Virginia. ........... 61,908 1.60 45,939 1.69 15,969 1.39 Washington.......... 70,743 1.83 52,715 1.94 18,028 1.57 West Virginia....... 31,610 0.82 2k, 550 0.90 7,060 0.62 Wisconsin........... 81,773 2.12 eh, 757 2.39 17,016 1.48 Wyoming: «revue ssiss T21XT 0.18 5,353 0.20 1,764 0.15 U.S. Service Schools 13,390 0.35 13,383 0.49 7 * Y The breakdown of total enrollments into full-time and part-time enrollment was estimated for a few insti- tutions whose enrollments represented only 1.8 percent of total enrollments. 167 2) Includes U. S. Service Schools. EDUCATIONAL ATTAINMENT AND FAMILY BACKGROUND Florence Campi According to a survey taken by the Census Bureau in October 1960, there were 4.7 million men 20-24 years old in the United States. Of this number, 1.7 million had either graduated from college or had some college attendance. The survey reveals a relationship between the level of education attained by young people and certain factors in their family background. There is a direct relationship between the college attendance of young men and the education of their fathers. College enrollment rates of men in their early twenties whose fathers were college graduates are several times as large as those for persons of the same age whose fathers never finished high school. When the fathers had completed college, 88 percent of the sons 20-2 years of age had graduated from college or had some college attendance. In contrast, when the father had completed only high school, 65 percent of the sons had graduated from college or had some college attendance. In the nonwhite group where the father did not graduate from high school, only 7 percent of the children 16-24 years of age were enrolled in college. However, in the nonwhite group where the father did graduate from high school, 18 percent of the children 16-24 years were enrolled in college. There is also a direct relationship between high school graduation of young men and education of their fathers. Where the fathers had graduated from high school, 92 percent of the sons had graduated from high school including 65 percent who had some college attendance. But when the fathers had not completed high school, only 57 percent of the sons graduated from high school including 23 percent who had some college attendance. Educational Attainment is Related to Family Income. Among the families whose income was less than $5,000 a year, 55 percent of the children 16-24 years old had graduated from high school but only 19 percent went on to college. Where the families had an income of $10,000 or more per annum, 87 percent of the children had graduated from high school and 60 percent continued on to college. Mrs. Campi is the Reports Assistant, Office of Program Analysis, Office of the Assistant Secretary (for Legislation), U. S. Department of Health, Education, and Welfare. Based on U. S. Department of Commerce, Bureau of the Census; School Enrollment, and Education of Young Adults and Their Fathers: October 1960 by Dr. Charles B. Nam in Current Population Reports, Series P-20, No. 110, July 24, 1961. Health, Education, and Welfare Indicators, February 1962 168 The educational level which a person attains is a product of both the educa- tion of the father and the family income.¥ Where the father did not graduate from high school and the family income was less than $5,000 only 13 percent of the children had some college attendance. In contrast, where the father graduated from college and the family income was $10,000 or more, 89 percent of persons aged 16-24 years old had some college attendance. COLLEGE ATTENDANCE Percent RELATED TO EDUCATION OF FATHER AND FAMILY INCOME Percent 100 100 Father Attended College 80 a 80 60 t——0+ ~~ Father a High School Graduate, 60 Did Not Attend College 40 Lo Father Did Not Graduate From High School 20 20 0 | | 0 Less than $5,000 $7,500- $10,000 $5,000 $7,499 $9,999 and over Family Income *College attendance is also related to the occupation of the father. This re- lationship is indicated in the U. S. Department of Health, Education, and Wel- fare; Office of Education; Cooperative Research Monograph No. 8, "Factors Re- lated to College Attendance," which states "...High school seniors whose fathers (a) were in executive or professional occupations, (b) owned or managed busi- nesses, or (e) did office or sales work were much more likely to attend college than the seniors whose fathers (a) owned or managed farms, (b) were factory workers, or (ec) were in the skilled or semi-skilled trades." 169 LIMITED EDUCATIONAL ATTAINMENT: EXTENT AND CONSEQUENCES Edward W. Brice and Earl E. Huyck Persons with low educational attainment have great difficulty in meeting the economic and social needs of modern society. They have limited adaptability to changing requirements for employment, and they frequently are rejected for military service. Those who lack an education extending beyond elementary school are deprived of many opportunities for personal development and participation in community affairs. Often they cannot avoid unemployment and dependency. Persons who have less than 8 years of formal schooling thus lack, by and large, the background for effective performance as employees and as citizens. For these reasons they are frequently called "functional illiterates." ¥* Adults With Less Than Eight Years of School According to the 1960 Census of Population some 22.1 million persons aged 25 and over--22.2 percent of the adult population--had completed less than 8 years of schooling. Of this number 11.5 million were men and 10.6 million were women. These "functional illiterates" are concentrated mainly in the follow- ing groups: (1) older persons, both white and nonwhite; (2) persons living on farms, especially Negroes; (3) persons with rural backgrounds who Dr. Brice is the Director of the Adult Education Branch, Office of Education, and Dr. Huyck is a Program Analysis Officer in the Office of the Assistant Secretary (for Legislation). Based on U. S. Department of Commerce, Bu- reau of the Census, U. S. Census of Population: 1960, General Social and Economic Characteristics, Final Report PC(1l) Series of State volumes; and "Literacy and Educational Attainment: March 1959, "Series P-20, No. 99, February 4, 1960. U. S. Department of Labor, Bureau of Labor Statistics, "Educational Attainment of Workers 1959," Monthly Labor Review, February 1960. * "Functional illiteracy" may be contrasted with "illiteracy." The Census Bureau defines an illiterate as "a person who cannot both read and write a simple message either in English or any other language." The ability to read and write is now shared by nearly all persons ll years old or older; the relatively small number of illiterates is concentrated mostly in the older age groups. Because of the demands of present-day family, community, and national life, this restricted definition of illiteracy is of limited usefulness. More meaningful today is the concept of "functional illiteracy," which is related to low educational attainment as measured by number of years of school completed. Health, Education, and Welfare Indicators, April 1962 Revised March 1963 170 have moved to urban centers, including Puerto Rican migrants; and (4) migrant farm workers and other disadvantaged groups, including Spanish-~ speaking persons in the western and southwestern United States. Data from the 1960 Census of Population show that: + There are about one million Puerto Ricans in the United States. Some 269,000 of those who are 25 years of age or older live in the five boroughs of New York City. Of these, 53 percent had completed less than 8 years of education. Similar percentages are reported for Jersey City and Philadelphia. : + A large number of persons with Spanish surnames live in the five southwestern States. A substantial proportion of them have had less than 8 years of school. Of the 101,000 such persons living in San Antonio, Texas, the rate was 69 percent. * In the United States territories of Guam, Puerto Rico, and the Virgin Islands there are 676,000 persons 25 years of age and older with less than 8 years of school completed, The rate varies from 39 percent in Guam, to 61 percent in the Virgin Islands, and Tl percent in Puerto Rico. Distribution of Functional Illiteracy Among the States The problem of limited educational attainment is not, however, limited to particular areas or population groups. Rather it is national in scope. (See accompanying chart and maps.) In New York State the number of adults with less than 8 years of schooling is nearly 2,000,000. In Illinois there are 1,048,000 and in California, 1,300,000. The corresponding numbers in Kentucky, Michigan, New Jersey, and Ohio exceed 500,000, while in Indiana, Maryland, Massachusetts, Missouri, Oklahoma, West Virginia, and Wisconsin the numbers range from 304,000 to over 500,000. Consequences of Limited Educational Attainment Lack of schooling results in lower earning capacity, higher rates of unemployment, more dependence on public aid, and higher rejections for military service. 1. Occupation and Earnings A direct relationship exists between an adult's educational attainment, his occupation, and, consequently, his earnings. The amount of formal schooling a person has received is a major determinant of his occupational group. Among men 18 years old and over in 1959, 60 percent of the college graduates were in professional and technical fields, and about in Persons 25 and Over with Less Than 8 Years of Schooling New York Texas Pennsylvania California Illinois North Carolina Ohio Georgia Virginia New Jersey Michigan Lousiana Tennessee Florida Alabama Kentucky Missouri Massachusetts South Carolina Maryland Persons (in thousands) 600 1200 T T T 1 1800 0 Indiana Mississippi Wisconsin Arkansas West Virginia "Oklahoma Connecticut Minnesota lowa Washington Kansas Arizona Colorado Oregon Rhode Island New Mexico D.C. Nebraska Maine Hawaii North Dakota New Hampshire South Dakota Delaware Montana U.S. Total (50 States and D.C.), 22.1 MILLION with less than 8 years of schooling 22.2 PERCENT of persons 25 years and over Percent in Age Group 10 20 30 40 50 Ll Utah Idaho Vermont Wyoming Nevada Alaska 1 1 1 i Source: U.S. Department of Health, Education, and Welfare based on 1960 census data supplied by the U.S. Department of Commerce, Bureau of the Census. 172 Thousands of Persons 25 Years Old and Older With Less Than 8 Years of School Completed \ £=4 \ \ Puerto Rico |@ Virgin Islands Source: U.S. Department of Health, Education, and Welfare based on 1960 census data supplied by the U.S. Bureau of the Census Percent of Persons 25 Years Old and Older With Less Than 8 Years of School Completed \ Puerto Rico |= Virgin Islands 5 Percent Q 3 []o-149 o Alaska Hawaii oO [1] 15.0-29.9 Ea 30.0+ Source: U.S, Department of Health, Education, and Welfare based on 1960 census data supplied by the U.S. Bureau of the Census 173 20 percent were managers, officials, or proprietors. Among men who completed high school, but did not go beyond, a majority were found in three occupation groups--craftsmen; operatives; and managers, officials, or proprietors. Those with some high school, but lacking four complete years, and men who finished elementary school, but who did not go on to high school, were most likely to have become oper- atives or craftsmen. Those with lesser amounts of education were most usually found--when employed at all--in farm, service, and unskilled laboring jobs. Of all employed men, as of 1957, in the age group 35-5k4 who had completed less than eight years of elementary school, 92 per- cent earned less than $6,000 per year. In contrast, 65 percent of high school graduates and only 29 percent of college graduates had income below this level. Employed workers with an eighth grade education or less have 65 percent of the incomes between $1,000 and $1,500, and 61 per- cent of the incomes between $1,500 and $2,500. 2. Unemployment and Underemployment Unskilled workers have the highest rates of unemploy- ment and the lowest average level of education. A Department of Labor study for March 1959 showed an unemployment rate of 10.0 percent for workers with under 5 years completed, a rate of 9.8 percent for those with 5 to 7 years schooling, 4.8 percent for high school graduates and 1.8 percent for college graduates. These rates had not changed substan- tially by March 1962. The rate of unemployment in 1962 among proprietors, managers, professional and technical personnel was between one and two percent. Clerical and sales workers were unemployed at the rate of ap- proximately four percent. But semi-skilled workers were out of work at the rate of 7 1/2 percent and unskilled workers at the rate of .about 12 percent. 3. Public Assistance Recipients of public assistance are more likely to be persons of low educational attainment. A 1957 study in New York, for example, revealed that almost a fifth of the mothers on the aid to dependent children rolls had not gone beyond the fifth grade. This study further showed that among families receiving general assistance half the family heads had completed no more than six years of schooling. Illinois reported in 1960 that a fifth of their ADC mothers had not gone beyond the sixth grade. In Louisiana, in 1954, half the ADC mothers and three-fourths of the fathers in the home had received only a fifth grade education or less. 17h Projected Educational Attainment Millions of Persons 25 Years and Older 28 seme 100 —— 50 — 25 NN Bb 1950 1960 1970 1980 Source: U.S. Department of Health, Education, and Welfare based on data appearing in Current Population Reports, Population Characteristics, Series P-20, No. 91, published by the U. S. Department of Commerce, Bureau of the Census. Projections used were Series II for population and Series A for educational levels. 175 College High School 4. Military Service In World War II, some 400,000 illiterates were accepted for military service. The armed forces provided these men with the educational fundamentals necessary for useful service. Another 300,000 illiterates--equal to twenty army divisions--were rejected completely. During the Korean War over 19 percent of all recruits were rejected from military service on grounds of educational deficien- cies. Experience showed that many of these men could learn, but over- coming their previous educational deprivations was costly and time- consuming. Draft registrants rejected for "mental reasons," including educational deficiencies, ranged from 56 to 39 percent in the four high- est States. Ten other States had rejection rates exceeding 21 percent. From July 1950 to September 1961, over 900,000 draft registrants out of 6 million examined were rejected on the basis of a mental test alone. This number was almost as many as were disqualified on medical grounds. Low educational attainment was the largest single reason for rejection. Projected Educational Attainment of the Population Although lower educational attainment is most prevalent among older persons, the problem will continue for many decades. The Census Bureau estimates that by 1980 there will still be more than 5 million persons 25 years of age and older with less than 5 years of education completed and 21.5 million with less than 8 years if present trends continue (Chart and Table). Projected Educational Attainment Years of school Millions of persons 25 years and over completed 1950 1960 1970 1980 13+ 11.9 15.7 20.k 28.2 9-12 353 Lh .8 57.3 76.0 5-8 32.6 30.5 26.0 21.5 0-k 9.8 8.0 6.4 5.2 TOTAL 87.5 99.0 110.0 130.8 176 PERSONS 25 YEARS OLD AND OVER WITH LESS THAN 8 YEARS OF SCHOOL COMPLETED (As of SpE 1, Li Census) Resident population 25 years and overd Less than 8 years State Total of school completed? Ygdien school years completed 000's P moles | Total Witte | Nomwmite TOTAL oc cincnmssmencacnin wo 100, 375 22,732 22.6 UNITED STATES (50 states and D.C.) 99,438 22,056 22,2 - 10.6 10.9 8.2 Alabama. «oun svumenns 1,670 643 38.5 LT 9.1 10.2 6.5 AlasK8...eueeeennnn. 105 16 13.7 17 12.1 12.4 6.6 Avizons.orevvrrnnes 661 138 20.9 30 11.3 1%.7 7.0 APKBBBEE vo snvamesne 96k 331 34.4 43 8.9 9.5 6.5 Californi@.......... 8,869 1,300 iT 13 12.1 12.1 10.5 COLOZEAD. «sass sinnsse 9k1 126 13.4 10 12.1 12.1 11.2 Connecticut, ........ 1,482 274 18.5 26 11.0 11.1 9.1 DENAVIR cum wmnmiasaisin 246 48 19.6 28 11. 1.6 8.4 District of Columbia L61 98 21,2 31 11.7 12.4 9.8 Florida.....ooovunn. 2,845 650 22.8 34 10.9 11.6 7.0 Georgia. ..coeveeann. 2,015 811 40.3 48 9.0 10.3 6.1 Hawaii...oeeeuuennnn 309 82 26.7 38 11.3 12.4 9.9 TAANO. eve vnnnnnenns 340 37 10.8 2 11.8 11.8 9.6 T114n04S.eeveennnnn. 5,808 1,048 18.0 ol 10.5 10.7 9.0 Indiana. ...cooceunn.. 2,550 432 7.0 19 10.8 10.9 9.0 TOWB. eeu eeerennnnans 1,541 211 13.7 11 11.3 13.3 9.5 Kansas. ....oeeeennn. 1,216 159 13.1 8 11.7 11.8 9.6 Korbueky,: «+ oommmwrs 1,610 535 33.2 42 8.7 8.7 8.2 Loulsiang. «veverrnss 1,639 688 41.9 50 8.8 10.5 6.0 Maine. ..oevenennennn 534 84 15.7 16 11.0 11.0 10.7 Maryland..... Fone 1,693 461 27.2 39 10.4 1.0 8.1 Massachusetts....... 3,011 523 17.4 20 11.6 11.6 10.3 Michigan. ........... 4,219 739 17:5 21 10.8 110 9.1 Minnesota. .......... 1,845 269 14.6 14 10.8 10.8 9.9 Mississippi.eo.ecc... 1,065 403 37.8 46 8.9 11.0 6.0 MisSSOUri..vveeunnnn. 2,493 535 21.5 32 9.6 9.8 8.7 Montana. ......oovu.. 356 Lh 13.3 9 11.6 11.7 8.7 Nebraska. ........... 791 9% 12.2 7 11.6 1.7 9.6 Nevada. eoeeeeennnnn. 160 17 10.9 3 12.1 12.2 8.8 New Hampshire....... 345 56 16.3 18 10.9 10.9 11.7 New Jersey 3,600 739 20.5 29 10.6 10.8 8.0 New Mexico ” Lhs 108 2h.2 37 11.2 11.5 7.1 New York. ..eeeeovn.. 10,124 1,969 19.4 27 10.7 10.8 9.4 North Carolina...... 2,307 956 h1.4 kg 8.9 9.8 7.0 North Dakota........ 324 59 18.4 25 9.3 9.3 8.4 OliGecsussssesssrsns 5,378 954 17.7 22 10.9 11.0 9.1 Oklahoma. «oe veeenn. 1,300 304 23.4 35 10.4 10.7 8.6 Oregon. .veeeeeenanns 996 121 12.1 6 11.8 11.8 9.9 Pennsylvania........ 6,606 1,425 21.6 33 10.2 10.3 8.9 Rhode Island........ 498 118 23.6 36 10.0 10.0 9.5 1,136 493 43.4 51 8.7 10.3 5.9 360 50 13.8 12 10.4 10.5 8.6 1,912 666 34.9 Ly 8.8 9.0 145 5,031 1,514 30.1 ko 10.4 10.8 8.1 hig 38 9.0 1 12.2 12.2 10:3 213 31 14.6 15 10.9 10.9 10.5 2,083 756 36.3 45 9.9 10.8 7.2 Washington.......... 1,571 185 11.7 5 12.1 12: 10.5 West Virginia....... 1,000 305 30.5 41 8.8 8.8 8.4 Wisconsin........... 2,175 387 17.8 23 10.4 10.4 9.0 Wyoming. ...eooeeueen 17h 20 11.6 Ly 12.1 za 9.3 GUA. es setensrnnnnsns 28 i 38.8 Puerto Rico......... 925 656 70.9 Virgin Islands...... 1h 9 61.2 Source: U. S. Department of Health, Education, and Welfare; based on U. S. Department of Commerce, Bureau of the Census; U. S. Census of Population: 1960, General Social and Economic Characteristics, Final Report, PC(1) series for each State. 1/ Resident population includes institutional population but excludes armed forces abroad. ased on years of '‘regular’’ schooling completed through formal education obtained in public and private kindergartens and graded schools. Tr LIBRARY SERVICES Wilbur J. Cohen and John G. Lorenz The Nation's investment in libraries is a most direct and effective investment in our vital intellectual resources. The public library, for example, has served as both school and college for millions of Americans. Increasingly, the well-stocked library is a source of books and materials required to keep abreast of technological and professional advances in a wide range of essential occupations. Good, modern public libraries play an important role in the whole spectrum of adult and continuing education, with tangible benefits to business, industry, and the professions. Our major library needs today are not limited to rural areas. About 128 million of our people have inadequate library services or none at all, and approximately half of these are in urban areas. Nor are needs limited to public libraries. About two-thirds of all the elementary schools in the country are without libraries, and many college libraries are inadequate. Such inadequate school and college libraries place additional, and often very severe, burdens on the public libraries. Major factors influencing the development of libraries in general in the 1960's are: (1) increased demands for library services related to population and economic growth, (2) shortages of library manpower, (3) the construction and equipping of physical facilities, and (4) the increasing volume and cost of library materials. Population and Economic Growth The 69 million children born since World War II (1946-62)--more than one-third of the total population at present--create needs for pre- school, school, and college-related reading materials and libraries. The greater part of postwar babies are now in elementary and: secondary schools and about 1965 will begin to reach college age. The population of the United States--187 million in 1962 and growing by three million persons each year--may reach a level of 250 million by 1980. More than three-fourths of our population may then live in urban Mr. Cohen is Assistant Secretary for Legislation, U.S. Department of Health, Education, and Welfare; Mr. Lorenz is Director, Library Services Branch, U.S. Office of Education. Date are based on publications and studies of the Library Services Branch including: The Cost of Library Materials: Price Trends of Publications; State Plans Under the Library Services Act with supplements; and reports on public libraries, public school libraries, and college and university libraries. Library standards are those of the American Library Association, Chicago 11, Illinois. Health, Education, and Welfare Indicators, December 1962 178 Population Trends—Prologue to Library Development areas--as many as there are in the Population by Age, 1950-1980 entire United States today. Accord- (Age in Years) ing to the trend projections of the Office of Education, enrollment in the elementary and secondary schools may increase over 23 million, or 55 percent, between 1960 and 1980. By | the fall of 1975, as many as 8.6 1 million persons--or half of the persons of college age--may be college students. Millions 250 4 r 200 The postwar children will i also become the Nation's workers in the next few years. The labor force is expected to increase from Th mil- lion in 1961 to 80 million in 1965 and 95 million in 1975. To remain competitive in domestic and world oe markets, the Nation's industrial or] plant is geared to rapid evolution 20-44 in its processes and proceudres. The demands for research, and the PE at allocations of personnel and expendi- 07 r""] 1 tures for research, will rise accord- 45-64 ingly. These developments underscore the needs for expanding employment opportunities and for raising the — | esa OR level of skills of the labor force 1 1 1 1 1 1 . . . . 1950 1955 1960 1965 1970 1975 1980 through training and retraining. <«—0BSERVED PROJECTED Source: Hauser and Taitel, ‘Future of Library Service: Demo- + graphic Aspects and Implications,’’ Library Trends, July 1961, Univer- The already substantial sity of Illinois Graduate School of Library Science. Projections based contribution of libraries to the upon U.S. Bureau of the Census, Current Population Reports, Series . P-25, No. 187. research effort will be enhanced through electronic data processing in retrieving stored information rapidly. Such experimentation is now underway at Western Reserve University in the field of educational research. But more basically, libraries complement each level of the educational and training process. Libraries can also supply the cultural materials to make meaningful the increased leisure time that is expected. No one type of library has the sole responsibility for contributing to the broad objective of producing mature citizens, capable of acquiring and applying knowledge in the workaday world of science, business, industry, and government, in family living, and in other aspects of human endeavor. Good libraries for people of all ages and all levels of educational attainment are essential to reach this objective. 179 Library Manpower and Professional Training Books and buildings alone do not make a library. Men and women of high professional ability are required, with sufficient supporting staff, to plan and carry out library development and services. The lack of adequately trained professional library staff is critical. Administrators of every type of library are concerned with professional vacancies--numbering more than 4,500 at present--and with the general lack of qualified staff to advance library service to at least minimum standards. There are now about 59,000 professional librarians serving in various types, of libraries, including an estimated 10,000 in special libraries. According to American Library Association standards, about 103,000 additional professional librarians are needed for minimal service in public, school, and college libraries. Professional Library Personnel Requirements (In thousands) Full-time professional librarians . . Needed according to American Type of library Libraries | my) oyed | Library Association standards Total Additional All 58.8 58.6Y 152.0 103.4 Public 8.2 19.5 28.0 8.5 School2/ 41.0 19.4 111.8 92.1 College & university 2.0 9.7 12.2 2.5 Special (estimated) 7.6 10,0 -- -—- 1/ Exclude 15,000 to 20,000 part-time or partly trained librarians. 2/ Data are for centralized public schools serving 150 students or more, representing sbout 97 percent of the total public school enrollment. The number of men in library work has been increasing during the past five years, but their proportion of the total number entering the profession has remained at one-fourth. There are twq major categories of professional library education institutions offering degree programs: those accredited by the American Library Association (31) and others (68). The ALA-sceredited institutions offer a fifth-year program normally leading to a Master's degree in library science and most also offer training below the Master's level. Seven have doctoral programs. The non-ALA~ accredited institutions may offer a Bachelor's program with a major in library science, a Master's program, or both. While the ATLA-accredited institutions provide training for various types of libraries, the others generally train only for school and public librarianship. 180 There has been a definite upward trend in librarian education during the past decade, with the total number of degree-granting institutions increasing 40 percent from TO in 1951-52 to 98 in 1960-61. The number of degrees granted has increased at a similar rate, from 1,721 to 2,3TL, or 38 percent. Of the degrees awarded in 1960-61, the ALA-accredited institutions awarded 1,675, or Tl percent. Library Science Degrees Institutions granting library science degrees Accredited by the American Total Library ol Diner School Degrees conferred Degrees conferred Yous Per-) Aver- Ter Aver- ending } cent | 2a8e 4 age Schools |Degrees pun Number | of | DRum- we Number or num- to- ber [°€T ny ber tal | Per tal per school school 1952 T0 1,72v |=-- ——— =—- —_—| =—- ——— -== -— 1955 8k 1,827 | 30 1,351 | 73.9| 45 54 LW76|26.1 8.8 195% 95 | 1,967 | 30 | 1,350] 68.6] LS 65 617!3L.Lk 9.k 1960 98 2,262 30) 1,430 | 63.2] 47.6 68 832136.8 12.2 1961 98 2,371 | 30 1,675 | 70.6] 55.8| 68 696 29.4 10.2 1/ Although ALA standards of accreditation for the fifth year Masterls program were approved July 13, 1951, evaluation and approval of all the 30 schools included above was not completed until 1958-59. 2/ 31 schools as of 1961-62. Physical Facilities The construction and maintenance of library facilities represent an important cost item in the provision of adequate library services. The era of Carnegie grants for public library buildings has long since passed. In March 1962 the U. S. Office of Education estimated the median age of public library buildings at 53 years of age. Thirty percent were probably built before 1910; 85 percent, before 1920; and only 4 percent, in the last 20 years. The Library Services Act, passed by Congress in 1956 in order to stimulate rural library development, does not provide funds for the purchase or erection of buildings or the purchase of land. The Office of Education projects the need for the construction of public libraries during this decade and the next at $528 million: Needed Public Library Construction (in millions of dollars) Places 1960-69 1970-79 10,000 population and over 137.1 193.1 Below 10,000 population 81.9 115.5 Total 219.0 308.6 181 Although there are no current statistics on school library facilities and equipment, many schools have inadequate, crowded and poorly equipped libraries. Many school buildings have no space for school libraries. Limited data on college and university construction needs indicate that the $300 million planned for library buildings for the period 1956-70 represents only about half the actual need. Library Materials The collection, organization, and maintenance of library materials are activities common to all types of libraries. The increasing number of book titles appearing each year is indicative of the "information explosion" and of the expanding universe of books to be considered for purchase by librarians. As many book titles were produced worldwide during the first 60 years of this century as were produced between the years 1450 and 1900. Within the United States the number of titles published rose from 10,027 in 1930 to 18,060 in 1961. The cost of books and other printed materials remains one of the principal expenditures of U. S. libraries. In 1960 libraries spent an estimated $125 million for books, periodicals, and other library materials. Prices of library materials are rising more rapidly than consumer prices generally. The cost of the average U. S. book rose 62 percent from $3.59 to $5.81 between the 1947-49 base period and 1961. The average periodical subscription rose 56 percent from $3.62 to $5.63 whereas consumer prices rose only 28 percent. Index: 1947-49=100 Prices of Library Materials and of Consumer Goods and Services Index: 1947-49100 175 F175 While there are factors common to all types of libraries, there are characteris- tics and problems which are unique to specific types of libraries-- public, school, college and university, and special libraries. 145 ns Public Libraries The Nation's public libraries made a marked advance in 1961 in public resources devoted to their operation and in services provided. Yet neither the increased resources nor the increased public usage has resulted in a significant approach to standards of minimum adequacy set by the American Library Association. 182 ADEQUACY OF PUBLIC LIBRARY SERVICE IN THE UNITED STATES June 30, 1961 POPULATION (In Millions) 50.5 AT LEAST MINIMUM ADEQUATE PUBLIC LIBRARY SERVICE INADEQUATE OR NO LOCAL PUBLIC LIBRARY SERVICE | 65.4 624 <€— Inadequate Service <«€—No Local Service 127.7 Source: Preliminary data reported by the State Library Agencies based on their criteria for adequacy of service. The majority of these agencies followed American Library Association standards. ‘‘Rural’’--area with less than 10,000 population; ‘‘Urban’’--area with 10,000 population or more as defined in the Library Services Act regulations. Nationally, according to preliminary reports sub- mitted by the State library agencies and based on their standards, 18 million persons in 1961 had no legal access to public library service and 110 million persons had only inadequate service available to them. Only 50.5 million persons had minimum adequate library service. Of the 8,190 public library systems in the Nation, there are 825 systems serving population groups of over 35,000 and accounting for 65 percent of the total population. Although many individual librar- ies may attain standards of minimum adequacy, the 825 major public libraries as a group only approach modest standards in respect to size of book collec- tion, number of new volumes added, number of personnel available, and overall oper- ating expenditures (exclusive of capital outlay). These largest libraries in fiscal year 1960 added 10.5 million volumes to their holdings of 130.5 million volumes and circulated nearly 455 million volumes. Employing 35,500 staff members, of which one-third are professionals, they had operating expenditures in excess of $194 million and capital outlays amounting to nearly $35 million. The resources of even these largest libraries indicate the availability of only 1.17 volumes per person. To provide minimum adequate service according to American Library Association standards, their library collections would have to be expanded by 19 percent, their staffs by 22 percent, and their operating expenditures, by 42 percent. Public Libraries, 1960 Professional Expenditures (millions of dollars) Volumes librarians Capital . . (millions) (tnonsanis) Total cali Salaries | Materials Other 200 19.5 060% 36 160 46 18 1/ Estimated per capita expenditure for people with public library services was $1.62. 183 School Libraries A good school library contains a varied collection of many materials chosen especially to serve the school's program of instruction and the needs of individual pupils. It can yield immeasurable returns in expanding intel- lectusl horizons and achievements. To be more than a storehouse and to function effectively, a school library must be an inherent part of each school rather than a branch of a public library and it must be directed by trained librarians. A 1958-59 Office of Education survey of public school libraries in school districts with enrollments of 150 and over showed that more than 10 million pupils were attending schools without centralized libraries. The lack of libraries was particularly serious in elementary schools. Schools (in thousands) Pupils (in thousands) Type of With centralized With centralized school Number libraries Number libraries Number Percent Number Percent of total of total All 82.2 41.5 50 33,716 23,046 68 Elementary 59.5 20.3 34 19,655 9,620 Lg Secondary 13.6 13.1 97 9,312 9,366 98 Combined, Elem. & Sec. 9.2 8.1 88 4,550 4,060 89 Even though schools may have centralized libraries, they do not necessarily have the trained librarians or the materials to provide adequate services. At the time of the 1958-59 survey, there were 19,400 school librarians who had hh Tone 23 PUBLIC ELEMENTARY AND The SECONDARY SCHOOL LIBRARIES library science. ratio of qualified Existing Library Service and American Library Association Standards librarians to pupils Reusing ET ALA Stondord was one librarian to 1,740 pupils whereas the national standard, established by the American Library Association, is one librarian to 300 pupils. The 5.3 library books per pupil and $1.60 annual expenditure per pupil in 1958-59 for books were also below the American Library Association national standards of 10 books and $4 to $6 annual expenditure per ANNUAL PUPILS PER 1 EXPENDITURES LIBRARIAN pupil. FOR BOOKS (per pupil) Source: The Library Services Branch survey covered about 15,500 school districts (36 percent of all public school districts) and 29.5 million pupils (97 per- cent of all pupils in public schools in the U.S. in the school year 1956-57). *In schools with centralized libraries. 184 College and University Libraries With the move toward more student initiative in learning and less lecturing in the classroom, greater reliance is being placed on library resources. National totals of college and university library collections are impressive, aggregating 190 million volumes in 1960-61--up 13 million volumes from the previous year. Academic libraries employed 9,700 librarians and an equal number of sub-professional and clerical employees to serve students and faculty in nearly 2,000 institutions of higher education. They spent $159 million--four percent of the total expenditure for educational and general purposes in their institutions. College and University Libraries, 1960-61 Library materials Employees | Expenditures (in millions) (in thousands) (millions of dollars) Volumes Periodi- Books cals Sala- and Added | at ena | received | Profes- | gppen| TOL [ries |periodi- |... during | _o year| during | sional opera= | ang cals er year year ting |yages and (Titles) binding 13 190 1.4 9.7 0.7 159 98 48 13 PUBLIC AND PRIVATE TT COLLEGE AND UNIVERSITY LIBRARIES outstanding libraries in the Existing Library Service and American Library Association Standards Nation. Nine of the largest BOOK COLLECTIONS institutions had collections ) totaling nearly 30 million 22% bowen (JEEMFORIIS BITTE | volumes and staffs totaling LL 1,000 librarians. Yet 1,200 86% soe wn nnn academic libraries failed to meet the minimum requirements LIBRARY PERSONNEL for adequate collections, and more than half of them failed 497% oe to measure up to minimal staff Pe requirements. SS ity pee Of all libraries in LIBRARY EXPENDITURES four-year institutions, 52 percent are sub-standard with 587 ees hn respect to collections (less akalivgaehin than 50,000 volumes), 49 percent 62% wee svn are sub-standard with respect to on! pnd librarians (less than three 0 15 30 as 60 [5] 90 professionals), and 58 percent Poth STE A nt EL SS are sub-standard in receiving less based an 1960-61 daca reported by 1.666 than five percent of total insti- colleges and universities. tutional expenditures. Libraries in two-year institutions are even worse off, according to American Library Association standards. 185 Despite present outlays, most academic libraries have difficulty in furnishing the library materials and professional staff services needed to make the best contributions to instructional and research programs. Further- more, many institutions, newly-founded or expanding their curriculums and enrollments need to assign higher than average budgets to their libraries. Library resources that are inadequate today will become less adequate when measured against anticipated enrollments and the necessity for increased research. Special Libraries A "special library" serves a business or industrial firm, a bank, a governmental agency, a newspaper, magazine, or advertising agency, or any other organization whose activity creates a need for library service within a particular field or discipline. Highly specialized departments in public and in college or university libraries are occasionally considered as special libraries. It is estimated that there are 10,000 persons employed in 7,500 special libraries in the following types of organizations: Associations, societies 3,000 Companies 2,800 Government agencies 1,750 Total 7,550 Inclusion of the special library departments of some 250 public and 2,200 college and university libraries would increase the total to 10,000 special libraries with some 15,000 employees. In addition, a Federal survey reveals that an estimated 850 persons are employed in approximately 90 technical information centers. Library Services Act The collection and publication by the Federal government of statistics relating to public libraries dates back to the 1860's and the inception of the U.S. Office of Education. The Federal legislative role in stimulating State and local action in the library field was recognized in 1956 with the passage of the Library Services Act (P.L. 84-597). Extended by P.L. 86-679 until June 30, 1966, the Act authorizes $7.5 million annually for grants to the States for the extension of public library services to rural areas (places of under 10,000 population). Under the stimulus of the Library Services Act: . 36 million rural residents have new or improved services. . More than 8 million books and other informational materials have been added, and over 300 bookmobiles have been purchased. . The States have greatly expanded their library extension services and have added 115 field consultants to assist local libraries. . State appropriations for rural public library services increased by $6 million, or 92 percent, and local appropriations increased by $22 million, or 71 percent, between 1956 and 1962. State appropriations for all public library services doubled from $12.3 million to $25 million. 186 Millions of Dollars Funds Available for Pyblic Libraries in Rural Areas Millions 6f Dollars 100 Funds Available for Public Libraries in Rural Areas & (Fiscal year data) Government 1956] 1957 1958 | 1959 | 1960 | 1961 | 1962 Millions of dollars 60 Total [29.4] 34.0) b7.7| sk.1| 60.1] 71.2 |\Th.6 Federal el 1h] 45.91 5.4] 7.18 ‘7.5 8.3 State 5:50 6.2 8.6 9.5] 20.1! 11.5 12.8 Local 23.8] 26.4) 3v.2| 39.2] 42.8] s2. 53.6 0 ercen Total [00.0[100.0 | 100.0 [100.0] 100.0 0 | 100.0 Federal ---1 4.2] 10.3] 9.9] 11.8] 10.4 | 11.1 State 18.9] 18.2 | 18.0 | 17.61 16.9 16.2 17.1 20 Local 81.1] 77.61 1..8 2.5] 7.3] 73.4 7.8 } ‘ 2. Data, supplied by States and outlying parts, may not add to totals due to rounding. 1959 The many positive achievements of the program should not over- shadow the magnitude of the job yet to be done. Preliminary data for 1961 indicate that 16.6 million rural residents had no legal access to local public library service and that an additional 49 million rural people had only inadequate service. Moreover, urban libraries in communities of over 10,000 population are ineligible for benefits under the Act and have, little financial incentive to participate in cooperative programs for extending service to adjacent areas. The Library Services Act | Expenditures under State plans by categories, fiscal years 1957-61 Millions of dollars 1 1/ Provisional data from reports filed with the U. 5. Office of Education by participating States and outlying parts under the Library Services Act. Data may not add to totals due to rounding. 3 Salaries and wages 1 Purchase of books | Purchase of i All other Tn vier Seeks Rise pOrLAnY Services” i and materials | equipment | operating expenses scal year data in thousands of dollars) ; ! | 1957 1958 1959 1960 1961 | 1 ' | ! g Total 5,679 | 15,290 | 16,783 | 19,757 | 22,266 i ' ! ] Level of government Source of funds 1 1 1 | ! | i Federal 1,305 | 4,430 | 5,218 | 6,646] 6,998 | : | State 3,124 [ 7,684 | 8,199 | 8,821] 10,114 | ! ! | Local 1,250 | 3,177] 3,366 | 4,290 5,154 } : | Category Usege of funds 1 1 ' 4 ! : : Salaries and wages | 2,241 | 7,054 | 8,171 | 9,300 10,439 | i : Purchases ! 1 ' T Books and materi- : | | , als 2,045 | book | 5,312 6,254 | 7,335 ) ! ' B Equipment 739 | 1,455 | 1,07h | 1,211 1,170 ! ! \ All other operating ! | ! expenses 65k | 1,857 | 2,226 | 2,903 | 3,322 ) ' ' ' | 1 i ' 1 1 1957 58 59 60 61 1957 58 59 60 61 1957 58 59 60 61 1957 58 59 60 61 187 DEVELOPMENTS UNDER THE NATIONAL DEFENSE EDUCATION ACT The National Defense Education Act of 1958 authorizes over $1 billion in Federal aid to education for programs that touch every level of education, public and private, from elementary through graduate school. The programs provided under the Act are designed to identify and educate more of the talent of the Nation, to improve the ways and means of teaching, and to further knowledge itself. Programs Under the Act The Act, as amended, authorizes the following Federal programs during the fiscal years 1959-1964 to encourage and assist in the expan- sion and improvement of certain aspects of education to meet critical national needs: Federal participation in college ana university student loan funds (Title II). Grants to States and loans to nonprofit private schools for purchase of equipment and improvement of State supervision to strengthen elementary and secondary school instruction in science, mathematics, and modern foreign languages (Title III). Fellowships for graduate study (Title IV). Grants to States and contractual arrangements with institutions of higher learning to strengthen guidance, counseling, and testing in secondary schools, and to establish institutes for secondary school guidance and counseling personnel (Title Vv). Modern foreign language institutes for elementary and secondary school language teachers, and language and area study centers for work in rarely taught modern languages, and for the conduct of research (Title VI). Research and experimentation in more effective use of modern communications media for educational purposes (Title VII). Grants to States for development of area vocational education programs in scientific or technical fields (Title VIII). . Grants to States to improve statistical services of State educational agencies (Title X). As of mid-1962, nearly $600 million had been obligated under the National Defense Education Act., Highlights of developments under the various programs authorized by the Act are described below. Health, Education, and Welfare Indicators, September 1962 188 Student Loans (Title II) Approximately 350,000 undergraduate and graduate students in 1,450 colleges and universities have borrowed $225 million under the student loan program to continue their education. The Office of Education furnished $202 million of this total. By June 30, 1962, about $5 million were repaid by students who have completed their college work. About one-fourth of the borrowers now paying off their student loans have become elementary or secondary school teachers. Science, Mathematics, and Modern Languages (Title III) The Office of Education and State educational agencies, on a 50-50 matching basis, have earmarked approximately $300 million, for new labora- tory and other equipment and minor remodeling of classrooms to improve the teaching of science, mathematics, and modern foreign languages in the Nation's public elementary and secondary schools. In addition, loans totaling $2.7 million have been made to approximately 180 private elemen- tary and secondary schools for this purpose. More than 15,000 public classrooms have been remodeled under this program, and more than 4,000 new electronic language laboratories have been constructed. Well over half of the projects have been in small schools with less than 1,000 students, and more than 90 percent of all local school districts have received funds for equipment to teach science. Some States report a doubling in enrollments in language classes in both elementary and high schools, and increases in science and mathe- matics enrollments are general throughout the Nation. More than half of the money lent to private schools has been used to teach science or modern languages for the first time in their history. As a further boost, an additional $7.9 million in Federal funds enable State educational agencies to increase their specialists in science, mathematics, and modern foreign languages from 33 in 1958 to well over 200 by 1962. Graduate Fellowships (Title IV) Grants have been made to 5,500 students under the graduate fellow- ship program, designed to train college teachers to help meet the current shortage. Thus far, $58.6 million has been obligated for this program-- half of which has been paid to the fellows and half to the 165 partici- pating graduate schools to help establish or expand the graduate programs in which the fellows are studying. Guidance, Counseling, and Testing (Title V) The Office of Education has made $47.8 million available to second- ary schools for guidance, counseling, and testing programs, and schools are now employing the equivalent of 21,800 full-time guidance personnel, as compared with only 12,000 before the passage of the Act. More than 11,000 men and women have attended special institutes to train for pro- fessional careers in counseling and guidance, or to improve their skills in these fields, at an estimated cost of $22.4 million. As a result of these activities, 17 million high school students have been given the opportunity to take scholastic ability and achievement tests under special counseling and guidance programs. Language Development (Title VI) More than 11,000 elementary and high school language teachers have gone to summer school at 218 recently established language institutes to learn new teaching methods and the use of new teaching materials. To date, more than $18.5 million has been obligated for improving language teachers' skills in this way. As another important phase of the language development program under the Act, 53 language and area centers have been developed in colleges and universities for full-time study not only of languages but of the countries in which the languages are spoken. Enrollment in the 1960-61 academic year reached nearly 7,000. Approximately $6 million has been obligated for this program. The modern languages taught in the centers are of major importance to government, business, industry, and education in this country. Spoken collectively by about 1 billion people, they include Arabic, Chinese, Hindi-Urdu, Japanese, Portuguese, Russian, and Spanish, as well as other neglected languages. The study of the countries involved include such courses as economics, history, and literature. In addition, more than 1,600 graduate students have been awarded fellowships for the study of 62 languages, a large percentage of them for study of languages of critical importance to our national purposes. Sixty colleges and universities offer courses for these students, and to date, $8.8 million has been obligated. As a first-time research effort, $10.4 million has been obligated for 206 projects to determine the greatest needs in foreign language instruction, to determine the best methods of foreign language teaching, and to develop instructional materials such as grammars, readers, and dictionaries. 190 The end product of the training course is the highly skilled technician whose knowledge is of sufficient range to permit him to shift with technological change. One example of the departure from traditional occupational training is the new classification of welder-metallurgist, a dual skill necessary to the welding trade because of the new alloys used in rocket and atomic submarine development. Thus far, $32.4 million has been made available to the States under this program. Matching on a 50-50 basis is required, but in the first 3 years the States overmatched by about one-third. Communications Media (Title VII) Nearly $10 million has been obligated to support 169 research pro- jects to determine the most effective way of using television, radio, motion pictures, teaching machines, tape recordings, and similar communications media for educational purposes. Research grants are made upon recommendation of the National Advisory Committee on New Educational Media. Nearly 60 have been completed. Over $l million has been obligated for getting into the schools information developed by research. Altogether, 113 contracts for this work have been awarded. Technical Training (Title VIII) Under the technical training program, both youths and adults are trained as highly skilled technicians in fields necessary for the national defense. Adults are generally workers who seek training for higher-level Jobs or who are brushing up on latest developments in their fields. Attendance at extension classes for adult workers reached 83,000 in 1961. More than 7,500 youths have already been trained as highly skilled technicians and graduated from the senior high school and post- secondary programs. More than 7,500 completed their training by the end of June. Total enrollments this year are expected to exceed 150,000 in the technical training programs, an increase of 150 percent over the first year of the program. Five thousand women enrolled in area technical training programs, chiefly in the fields of data processing and computer programming, electronics and mechanics. Placements of most graduates are in defense-related employment. Jobs were readily found for the graduates--in some States, there were not enough to fill the positions available. In one area, 600 students in data-processing techniques accepted jobs before their graduation. Pay for high school graduates who completed the additional 2-year courses in technical instruction, in the first 28 States reporting, was as high as $7,200 and averaged $4,600. Pay for graduates of the high school programs averaged $3,900. 191 SCHOOL ASSISTANCE IN FEDERALLY AFFECTED AREAS A total of $2.5 billion has been appropriated over the 12-year period ending June 30, 1962 for the program of financial assistance to local edu- cational agencies in Federally affected areas for current operating expenses and for construction of school facilities. This program of aid to "Federall impacted areas" was authorized under legislation (Public Laws 874 and 815) enacted in 1950. The primary objective of P. L. 874 is to provide financial assistance for the maintenance and operation of schools in those local educational agencies upon which the U. S. Government has placed financial burdens by reason of the fact that: (1) local revenues to school districts affected have been reduced as the result of the acquisition of real property by the Federal government, or (2) such agencies provide education for children re- siding on Federal property or for those whose parents are employed on Federal property, or (3) there has been a sudden and substantial increase in the num- ber of pupils in average daily attendance as a direct result of activities of the Federal government. In addition to grants to local educational agencies, the law provides that the Commissioner of Education shall make arrangements to provide free public education for children who reside on Federal property if no local educational agency is able to provide suitable free public education for such children. These arrangements are made either with a local educational agency or with the head of a Federal department or agency administering the Federal property on which the children reside. Public Law 815 provides Federal financial assistance for construction by local educational agencies of urgently needed minimum school facilities in school districts which have had substantial increases in school enrollment as a result of new or increased Federal activities or where many pupils re- side on tax-exempt Federal properties, principally Indian reservations. In addition, assistance is provided for the construction of minimum school faci- lities by the Federal Government on Federal property (such as Army, Navy, and Air Force installations) where under State law no State or local educational agency can provide these children with suitable free public education. Payments may be made to local educational agencies where evidence indicates that there has been, or will be, an increase in school enrollment of children residing on Federal property with parents employed on Federal property, and for children who either reside on Federal property or reside with a parent employed on Federal property, or where the increase in school enrollment has resulted or will result directly from activities of the United States, carried on directly or through a contractor. Source: U. S. Department of Health, Education, and Welfare; Office of Educa- tion, Administration of Public Laws 874 and 815: Twelfth Annual Report..., June 30, 1962 (OE-22003-62). Health, Education, and Welfare Indicators, March 1963 192 Numerous amendments made to Public Laws 874 and 815 since their origi- nal enactment in 1950 have liberalized the provisions of the laws in several respects, principally by increasing the rate of payment through the estab- lishment of certain minimum rates and by extending coverage to additional categories of Federally-connected pupils. P. L. 85-620, enacted in 1958, made permanent those provisions of the Acts authorizing payments for children who live on Federal property with a parent employed on Federal property. Legislation enacted in 1961 extended the temporary provisions of both P. L. 874 and P. L. 815 through fiscal year 1963. PROGRAM HIGHLIGHTS Maintenance and Operation (Public Law 874) * A total of $1.4 billion was appropriated for this program from its beginning in 1950 through fiscal year 1962. For the twelfth consecutive year the number of school districts and the total amount of their entitlements increased--$247 million was appropriated for FY 1962, as compared with $217.3 million for FY 1961. * The number of eligible school districts increased from 3,965 in FY 1961 to 4,065 in FY 1962. Increases were chiefly attributable to growth in school population and new or expanded Federal activities. + The total number of pupils in the 4,065 eligible districts in 1962 approximated 11 million, or about one-third of all pupils attending public elementary and secondary schools in the Nation. Federally connected pupils totaled more than 1.75 million, representing 15.2 percent of the total attendance in eligible districts. e Over 255 million acres in Federally owned property were claimed as a basis for entitlement in FY 1962. The number of different Federal properties claimed as a basis for payment totaled 5,288, an increase of 106 over 1961. * Local educational agencies were entitled to approximately $233 million in 1962, an amount equivalent to about 5.2 percent of current operating costs of eligible districts. Over $230 million of these payments was to meet educational costs for pupils who resided on Federal property or resided with a parent employed on Federal property. The remainder was to meet additional costs incurred by school districts that experienced sudden increases in enrollment due directly to activities of the U. S. Government or loss of tax revenue because of Federal acquisition of real property. Payments of over $13 million were made to Federal agencies or local educational agencies to provide public education to children re- siding on 48 Federal installations, chiefly military bases, where no local educational agency was able to provide suitable free public educa- tion. 193 Construction (Public Law 815) A total of $1.1 billion was appropriated from the beginning of the program in 1950 through fiscal year 1962. Federal funds amounting to $947 million have been reserved for 4,961 construction projects submitted by approximately 1,840 different local school districts. Of these projects, 1,326 are new elementary schools and 1,963 are additions to elementary schools, 461 are new secondary schools and 846 are additions to secondary schools, and 365 are for improvements to existing facilities such as equipment and heating plants. Of these projects, 4,469 are completed, LOT are under construction, and 85 are in the preconstruction stage. To the Federal funds, school districts have added an estimated $670 million (exclusive of site, off-site improvements, and other costs) for a total of over $1.6 billion used to construct 53,345 classrooms and related facilities for 1,547,000 pupils. Of the total granted to local school districts, almost $42 million has been allocated under section 1k (formerly Title IV) to 250 projects to provide 1,428 public school classrooms for 40,900 pupils (primarily children living on Indian reservations), and funds for 40 projects costing over $7.5 million have been reserved for construction of tem- porary school facilities housing 13,900 pupils. In addition to the funds granted to local school districts, approximately $123 million has been allocated for Federal construction of 310 projects on Federal property, comprised of 3,241 classrooms and related facilities for 96,400 pupils living on Federal property. 194 PART IIL CURRENT AND EMERGING ISSUES AND OPPORTUNITIES Welfare and Income Maintenance 195 196 THE OLDER POPULATION Eugenia Sullivan As the number of aged people in the community grows, the problems of the older population become magnified. These problems center around inadequate incomes, declining health and physical capacity, increased need for health and medical services but decreased ability to pay for them, and inadequate or unsuitable housing. Number and Characteristics of the Aged One out of 11 persons in the United States is aged 65 or over, and the number of aged persons is growing at the rate of over 1,000 a day. The aged population is increasing both numerically and as a proportion of the total population. ©Since the beginning of the century the number of persons aged 65 and over has increased more than five-fold--from 3.1 million in 1900 to 17.5 million in 1963. This rate of growth has been far greater than that of the population as a whole and has changed the age distribution of the population. Older people were 4 percent of the population in 1900; today they make up 9.3 percent. The proportion MILLIONS OF PERSONS AGE 65 AND OLDER of older people is 20.0* expected to increase only slightly during the 1960-70 decade. Nevertheless, by 1970 there will be 20 mil- lion persons aged 65 and over and, on the average, they will be older than the present aged group. The highest proportionate increases in the aged 43 population are in the Age 75+] | oldest age brackets-- 75 and over. *Projected 1920 1930 1940 1950 1960 1970 Miss Sullivan is a Staff Assistant in the Office of Program Analysis, Office of the Assistant Secretary (for Legislation), U. S. Department of Health, Educa- tion, and Welfare. Based on data provided by: (1) Social Security Administration, Division of Program Research, The Health Care of the Aged, 1962; (2) Public Health Service, U. S. National Health Survey, Older Persons Selected Health Characteristics (PHS Pub. No. 584-Ck, 1960); (3) U. S. Department of Commerce, Bureau of the Census, Current Popula- tion Reports, Series P-60, No. 37, Income of Families and Persons in the United States: 1960; (4) Housing and Home Finance Agency, Senior Citi- zens and How They Live, Part I, The National Scene, July 1962. *The older population here is limited to persons 65 and over except that for the special tabulations on housing from the 1960 census the definition is broadened to include persons 60 and over. Health Education, and Welfare Indicators, November 1962 Revised 197 Increased longevity has brought about the dramatic increase in the aged population. The average life expectancy at birth has risen from 49.2 years in 1900 to an estimated 70.2 years in 1961. Life Expectancy (1961) is greater for women than for men (73.6 and 67.0 years) and greater for whites than for nonwhites (71.0 and 64.4 years). Women outnumber men in the over-65 age group; there are 124 women per 100 men aged 65 and over. Moreover, because women tend to live longer than men, the excess of women over men increases in the upper age brackets. In the group over 85 there are 158 women for every 100 men. Women's greater longevity coupled with the fact that they marry younger than men contributes to the preponderance of widows at the upper age levels. U.S. Population 65 Years ond Over, by Sex, 1961 MILLIONS OF PERSONS 751079 Years AGE GROUPS Source: Bureau of the Census, Current Population Reports, Series P-25. 80 to 84 Years 85 Years and Over Health Conditions of the Aged Health problems are a major concern of the aged population, since advancing age is accompanied by a decline in health and physical capacity. As a group, older people are more prone to chronic illness and as a result more likely to be partially or completely limited in activity than younger people. Illness and Disability Among Older People Older persons are twice as likely as those under 65 to have one or more chronic conditions. Data from the National Health Survey show that about four out of five persons aged 65 and over have one or more chronic conditions, as contrasted with two out of five younger persons. While some of these conditions are relatively minor afflictions, such as sinusitis, hay fever, or bronchitis, many more are serious conditions such as high blood pressure, heart disease, or diabetes. The incidence of chronic illnesses increases with age; the number of persons with one or more chronic conditions increases from T4 out of 100 persons in the age group 65-Th to 84 out of every 100 persons aged T5 and over. 198 Similarly, the extent of disability due to chronic illness increases with age. Well over half of the aged persons with one or more chronic conditions have some limitation of activity, whereas among younger persons with chronic illness, only one out of five has any limitation of activity. Among persons aged 75 and over who have one or more chronic conditions, partial or major limitation of activity occurs in about 2 out of 3 cases. Days of restricted activity and bed-disability days are another measure of the impact of chronic illness on the aged population. The National Health Survey showed that in 1960 people aged 65 and over were restricted in their usual activities an average of 38 days per year--more than 2% times as many days as younger persons. On 14 of these days, the aged person was confined to bed all or most of the time. The chief chronic illnesses of old-age are arthritis, rheumatism, heart disease and high blood pressure. Among .the population aged 65 and over during the period July 1957-June 1959, 149 per 1,000 persons had a heart condition, 129 per 1,000 had high blood pressure, and 266 per 1,000 had arthritis or rheumatism. Most Common Causes of Illness and Impairment Among Older People ARTHRITIS & HIGH BLOOD RHEUMATISM HEART DISEASE PRESSURE 45-54 55-64 65-74 75 and over Rate per 1000 pop. 100 200 100 200 100 200 | | | | | | IMPAIRED VISION IMPAIRED HEARING DIABETES 45-54 55-64 65-74 75 and over Many aged persons suffer from visual or hearing impairments. The National Health Survey reports that one out of 10 aged persons has impaired sight and one out of every six suffers from partial or complete deafness. Visual and hearing impairment rise sharply among persons over age 5. In this age group, one out of six has impaired sight and one out of four impaired hearing. 199 Although chronic illness is the major health problem of the aged, the incidence of acute illnesses among older persons, particularly respiratory conditions, is by no means insignificant. In many cases, acute illnesses may be the immediate cause of death for older persons with chronic conditions. A total of 134 acute conditions for every 100 aged persons was reported in 1959. Accidents, too, cause a considerable amount of disability among older persons. About one out of every four aged persons was injured in 1959, about two-thirds of them in accidents occurring in the home. The National Health Survey data on health conditions of the aged are based on household interviews and exclude persons in nursing homes, homes for the aged, and long-stay hospitals, as well as persons whose illness resulted in death during the survey year. For these reasons, the data present a more favorable picture of the health situation of older persons than is actually the case. Utilization of Medical Services As might be expected from the state of their health, older people utilize health facilities and medical services more than younger persons. They use a greater volume of physicians' services and are admitted to hospitals more often and stay longer. They are the primary users of nursing home and other long-term care facilities and receive a greater amount of home care, part of which is provided by nurses. They need and use more drugs. In 1959 persons aged 65 and over averaged 6.8 physician visits per year--two more than younger persons. The rate of physician visits was higher for women than for men and increased with the size of family income. Aged persons with limitation of activity due to chronic illness consult a physician more often than those without such conditions, and the number of physician visits increases with the severity of the condition. However, among persons with equally severe limitations, persons with higher incomes visit a doctor more often than those with lower incomes. Hospital utilization may be measured by several indexes, including hospital admissions or discharges, length of stay, days of care, and the number of persons hospitalized. Data from the National Health Survey for the two-year period ending June 1960 show that discharges from short- stay hospitals averaged 14.6 per 100 persons aged 65 and over as compared to 11.2 discharges per 100 persons under age 65. Aged persons spent, on the average, about 23 times as many days in the hospital as persons under age 65--218 days as compared to 85 days per 100 persons. Their average length of stay was sbout twice as long--1%.9 days as compared to 7.6 days for younger persons. Aged men remain in hospitals an average of 15.9 days as compared to 14 days for women. UTILIZATION RATES IN SHORT-TERM GENERAL HOSPITALS* Annual Patient Days per 100 Persons 218 Average Length Annual Discharges of Stay per 100 (Days) Persons 14.9 14.6 7.6 Under 65 and Under 65 and Under 65 and 65 Over 65 Over 65 Over *Based on household interviews of persons living at the time of interview. SOURCE : Public Health Service, U.S. National Health Survey, 1958-60 Since the Health Survey data exclude persons who died in the hospital or subsequently during the year before the interview, there is some understatement of hospital utilization. A survey based on hospital records indicates that the inclusion of hospitalization received by persons who died during the survey year would result in increases of one- fourth to one-third in the total volume of hospitalization for persons 65 and over. Insurance Coverage and Hospital Utilization Just over half of the aged population have some health insurance coverage, in most cases hospitalization insurance. The National Health Survey found a considerable difference in the rate of hospital utilization among insured and non-insured persons. The difference among insured and non-insured persons was greater in the group aged 65 and over than in any other age group. About 13.7 percent of aged persons with hospitalization insurance were hospitalized in 1959 as compared with 8.2 percent of those without insurance. 201 Fewer aged persons than younger persons have any part of their hospital bill paid by insurance, and, for those who are insured, the insurance pays a smaller proportion of the hospital bill than for younger persons with hospital insurance. Data from the National Health Survey for 1958-60 showed that of the total aged patients discharged from short- stay hospitals, 49 percent had no part of the hospital bill paid by insurance, 9 percent had less than half of the bill paid, and only 30 percent had three-fourths or more paid. Comparable data for younger persons showed only 30 percent with no part of the hospital bill paid by insurance and 54 percent with three-fourths or more paid. The actual percentage of aged persons who had insurance coverage for hospital bills and the proportion of the bill covered are probably smaller than the data indicate because persons who died during the year are not included in the survey. Insurance coverage in the older age groups, where the death rate is highest, drops sharply; in 1959 only 32.5 percent of persons aged 75 and over had any hospitalization insurance. Mental Illness Among Older People Mental illness is a serious health problem among older people. About one out of four first admissions to public hospitals for the mentally ill is a patient aged 65 or over. In 1960 the first admission rate for the aged was more than 3 times that of the population under 65. Some 82 percent of the persons admitted at age 65 and over were diagnosed as having senile or arteriosclerotic brain damage. Resident patients aged 65 and over in State and local mental hospitals numbered 138,600 in 1960--about 30 percent of the resident patient population. About half of the aged patients in mental hospitals are persons who were admitted at age 65 and over. However, statistics on the aged in mental hospitals reflect only a part of the problem of mental health of older people. Many older persons with psychological dysfunction are to be found outside of mental hospitals-- in nursing homes, in homes for the aged, and in the care of relatives or friends. Many of these persons require supervision in an institutional setting, but others, who have some behavior problems which require super- vision, may not need 24-hour institutional care. A survey of psychiatric services for the aged in metropolitan New York conducted in 1958-59 by the New York State Department of Mental Hygiene found that mental and physical disabilities of older people account only partially for their admission to mental hospitals, homes for the aged, and nursing homes. The lack of social, psychiatric, and other medical services in the community--particularly home-care services--is often the cause of such admissions. Of those admitted to homes for the aged, 57 percent were either persons with disabilities who were unable to care for themselves and had no relatives, friends, or others to care for them; or persons with physical, psychological, social, or financial problems beyond their capabilities without more help than the community now provides. Some 40 percent of those in State mental hospitals, but only 17 percent of those in nursing homes, had been admitted for these same reasons. 202 The study showed that some 90 percent of the inmates of homes for the aged and nursing homes, as well as State mental hospitals, have sufficiently disturbed behavior to be diagnosed as mentally ill. However, the proportion with severe mental impairments is greater in the State hospitals. In short, the type of institution to which an aged person is confined is not necessarily an indication of his physical or mental condition, since there is considerable overlapping in the frequency of physical and mental disorders among inmates of all three types of long- term care facilities. A report, "Mental Illness Among Older Americans," prepared in 1961 for the Senate Special Committee on Aging, points to the need for more community services designed to prevent mental hospitalization, improved services for the aged in mental hospitals, and more trained personnel in the mental health professions. The Financial Position of the Aged The decline in health and physical capacity of older people is accompanied by a decline in income. Annual incomes average substantially less for older persons than for people under age 65, reflecting the relatively large proportion of aged persons who have retired from the labor force and are dependent on types of income other than earnings. The most comprehensive information on the income status of the aged comes from the Current Population Survey of the Bureau of the Census. These data show that in 1960 the average annual income of families headed by a person over 65 was $2, 900--about half that for families headed by persons under 65. About three-fourths of families with aged heads were two-person families--usually husband-wife families. The average annual income for aged couples was $2,500, as compared with $5, 300 for younger two-person families. The proportion reporting annual incomes of less than $2,000 was over twice as large--36 percent among older two-person-families as compared with 16 percent of the younger two- person families. Aged persons living alone or with nonrelatives generally had much lower incomes than aged couples; the average was $1,053. The most important MEDIAN MONEY INCOME IN 1960 factors affecting the income @® TWO-PERSON FAMILIES: status of the aged in recent Head Under 65 E years have been the declining EL labor force participation of " the aged and the increase in Head 65 or Over DHMUIMBMAN $2,530 the numbers and proportion of the aged getting income from public income maintenance @® PERSONS LIVING ALONE: Programs Under 65 f: 650r over NNN $1,055 $5,315 i s2,570 203 Sources of Income In 1960, earnings from work were the sole source of income for only 10 percent of families with heads 65 and over. One-third of the older families reported no earnings. Over one-half had both work and other income. Older families with no earnings from work had the lowest incomes--about one-half had less than $2,000. Only one-fifth of the families with work income alone, or a combination of earnings and other income, had less than $2,000. Other income includes old-age and survivors insurance benefits, public assistance, payments from private pension plans, veterans' payments, interest, dividends, annuities, and rents. Among older persons living alone or with nonrelatives, a much smaller percentage--one-fourth--have earnings from work. Single aged persons who reported no earnings had about half as much incomes as those with earnings. Few of the aged work full-time. The majority of older people who work have part-time jobs or are employed for only part of the year. One out of 6 aged men and only one out of 25 women who had reached age 65 reported they were year-round, full-time workers in 1960. The Census study tends to underestimate total income because some types of income, such as realized capital gains and lump-sum insurance pay- ments, are not counted. Also, people are more likely to understate unearned income than earned income. Even after allowance for these factors, a sub- stantial proportion of older nonearner families had incomes totaling less than $2,000 in 1960. People 65 and Over Eligible for Social Security About T1 percent MUON; of the total aged popu- lation now get retire- NOT ELIGIBLE * 30 ment or survivors ELIGIBLE EEE benefits under the old- age and survivors insurance program. Over 78 percent of the aged 20 are eligible to receive such benefits. About 1% 15 million older people are not receiving benefits 10 because they are working and earning substantial amounts or are the dependents of such workers. 125 1961 (JAN. 1970 1980 2000 It is estimated that 89 percent of those now reaching age 65 are eligible for old-age and survivors insurance. The difference in eligibility 20k rates between persons now reaching 65 and the total aged population is due to the numbers of the latter, particularly in the older age groups, who retired before their work was covered by the old-age and survivors insurance program or who are the dependents or survivors of such workers. In the future nearly 95 percent of all persons reaching age 65 will be eligible for old-age and survivors insurance. Some 2.2 million aged persons are currently getting old-age assistance under the Federal-State public assistance program. About one-third of the old-age assistance recipients also get old-age and survivors insurance benefits, and about one out of two persons now coming on the old-age assistance rolls is also a social security beneficiary. About one out of ten aged persons get benefits under the railroad retirement program or the Federal employees retirement system. In 1961, for the first time, more aged persons--one out of nine--got benefits under the veterans' pension and compensation programs than under the programs for railroad and government workers. Payments under public income maintenance programs--the chief support of the aged population--are not large. In March 1963, the average monthly benefit to a retired worker under the OASDI program was $76; the average as benefit was $66. The average monthly old-age assistance payment was $76. Benefits tend to be larger under the programs for railroad and government workers. In March 1963, the average annuity of a retired railroad worker was $135. Payments to aged widows under the railroad retirement pro- gram averaged $72. Monthly payments to retired Federal employees averaged $181 in 1962. In mid-1962, an estimated 1-3/4 million aged Americans--about 1 out of 10 people aged 65 and over--were getting private retirement pensions. The majority of them were old-age and survivors insurance beneficiaries. Pension pliwns have expanded rapidly since 1950, when pensions became a prime ob, ective of collective bargaining. An estimated 23 million workers are now covered by such plans. But since much of the private pension coverage is of relatively recent origin, the full potential of private pension plans in providing retirement income lies largely in the years ahead. Current information on the proportion of aged persons getting other forms of income from private sources is almost nonexistent. It is estimated that in 1961 more than 600,000 annuities, purchased individually or elected as settlement under life policies, were being paid to persons aged 65 and over. The number of persons who draw income from this source is smaller because some persons receive more than one annuity. Some aged persons have other forms of property income such as interest, dividends, or rent, or get cash contributions from relatives. 205 Assets of the Aged Older persons are somewhat more likely than younger persons to have some savings, but in most cases these savings are not readily con- vertible to cash. The 1960 Survey of Consumer Finances, conducted by the University of Michigan Survey Research Center for the Federal Reserve Board, found that among spending units with heads aged 65 and over, 30 percent had no liquid assets, and 20 percent had liquid assets valued at less than $1,000. Equity in a home is by far the most common asset of the aged. Ownership of a home was reported by 64 percent of the older spending unit heads in the 1960 survey and more than four-fifths of the homes were clear of mortgage debt. More than half of the home owners reported the value of the home as less than $10,000. A 1957 survey of old-age and survivors insurance beneficiaries found that about two out of three of the married beneficiaries and one out of three nonmarried beneficiaries owned a nonfarm home. Most of these homes were mortgage-free, but the equity was relatively modest-- about $8,000 for married couples and widows and about $6,000 for single retired workers. Expenses of home ownership for urban couples who owned their homes mortgage-free averaged about 30 percent less than. the average outlay for rent and utilities by couples living in rented living quarters. Budgetary Needs of the Aged Some measure of the budgetary needs of older persons is needed in order to place in perspective the income data on the aged. The Bureau of Labor Statistics released data in 1960 on the budget costs for a retired couple representing a "modest but adequate level of living" for a couple in reasonably good health, living in rented quarters in an urban area. The cost of a retired couple's budget has been estimated by the Bureau of Labor Statistics to have ranged from $2,641 to $3,366 in twenty large cities in the fall of 1959. It would appear that the average annual income ($2,530 in 1960) of older two-persons families, the majority of whom are retired couples, is insufficient. Tax Benefits for the Aged Three special provisions of the Federal income tax laws benefit older people. These are the additional $600 personal exemption for persons 65 and over, the retirement income credit (exempting up to $1,200 of retirement income), and the special medical expense deduction over and above that available to younger persons. The Treasury Department estimated that during fiscal year 1962 taxpayers aged 65 and over saved about $742 million in personal income taxes as a result of the provisions. Of this total, $482 million represented tax savings from the double exemption, $120 million was from the retirement income credit, and $140 million resulted from the special medical expense deduction. 206 The greatest advantage from these tax provisions accrues, of course, to the minority of older people with high incomes. Tax benefits do not appreciably improve the financial position of older people who do not have substantial amounts of income apart from their social security benefits. The 1957 survey of old-age and survivors insurance beneficiaries found that well over half of the aged beneficiaries had less than $600 in income other than benefits. Families and Households Just over half of all aged persons are married and living with a spouse. But nearly two-fifths are widowed, and the majority of them are women. Almost half of the aged widows are 75 and over. About T out of 10 persons aged 65 and over live alone or in two- rerson households. The majority of the two-person households are husband - wife families, while 7 out of 10 one-persons households are comprised of women. Only a small proportion of the aged--less than 4 percent--are in institutions. Marital Status and Living Arrangements: Distribution of persons 66 and over, by sez and age, for the United States, March 1961 Male Female Total Status 65 and over Total [65to74| 75 and | Total |65to74| 75 and over Over Total, 65 and over...._..._._..___________ 100.0 44.8 29.8 15.0 55.2 35.0 20.2 Married, spouse present.._______ __ "TTT" 50.9 31.2 23.0 8.3 19.7 15.5 4.1 38.6 9.1 3.8 5.3 29.5 15.5 14.0 2.1 1.1 .8 .4 1.0 .8 .2 Lb .6 .4 “2 .9 .6 .3 6.8 7.7 1.8 .8 4.1 2.6 1.6 Other, by living arrangements: INPAINOS. cee ee eevesmnmin anne 23.1 6.0 2.6 3.3 17.2 8.8 8.4 Family head Spore not present).__. 8.2 2.0 1.2 .8 6.2 3.7 2.5 Relative of head (other than wife)....| 14.9 4.0 1.4 2.5 11.0 5.1 5.9 Living alone or lodging..._._________._._~ 22.3 6.1 3.5 2.7 16.2 9.6 6.6 In institutions. ___________ZTTTTTTTTTTTC 3.7 1.5 «7 Af 2.2 1.1 Ll Source: Bureau of the Census, Current Population Reports; Population Characteristics, Series P-20, No. 114. “Marital and Family Status: March 1 61,” January 31, 1962; and preliminary count of institutional inmates from the 1960 Census of Population, The 1960 census contained data on living arrangements of "elderly" people, broadening the 1950 definition to include all persons 60 years of age and over living in households. As of 1960 there were 22.2 million such persons in the United States. About TO percent were members of households owning their own homes, and the majority were heads of house- hold and their wives. About half of the persons 60 and over in 1960 who were living in households lived as two-person households, and about 4 out of 5 of these were husbands and wives living together. The remaining 50 percent of the elderly persons were divided equally among one-, three-, and four-or-more- person households. The extent to which older people have at least nominal 207 control over their living arrangements is indicated by the proportion who are household heads or wives of heads. Among both owner and renter units, the proportion is high--8l percent for owners and 84 percent for renters. Income and Living Arrangements Since income is a major factor influencing the living arrangements of senior citizens, the 1960 census analyzed both the individual income of elderly householders and the total household income of households containing elderly members. The analysis showed that the elderly head of a household had a much larger income than the oldest member who was 60 or over--$1,900 on the average, as compared to $800. The average for male heads ($2,400) was much higher than for females ($1,100). Household income (the combined income of all related household members) is, of course, a clearer indication of ability to pay for housing under present living arrangements than individual incomes. In 1960 the median annual income for all households containing elderly members was $3,300, well below the average for all households ($5,000). Although it is likely that renter households need more income than owner households to cover housing expenses, incomes of renter households averaged only $2,400, as compared to $3,800 for owner households. Type of Housing About 9 out of 10 owner households live in single-family housing units, about 9 percent, in structures with two or more units, and 1 percent live in trailers. Among renter households, 42 percent live in single-family units, 24 percent in two to four family structures, and 33 percent in buildings with five or more units. Whether older people are better off in single-family housing units or in more compact apartment units is debateble. Single-family housing offers the opportunity for pursuit of hobbies centering about the home and garden, while apartment living reduces burdens in upkeep and household chores. Equity in a home enables homeowners, as a group, to have lower housing expenses than renters, despite the burden of taxes and repairs. Because the average cash value of homes owned by older people is not high, most of these homeowners would be unable to obtain comparable rental housing if they sold their homes and invested the equity. The 1960 census data show that some 53 percent of the nonfarm homes owned by persons aged 65 and over were valued at less than $10,000. The median value of owner- occupied homes was $9,900 for those in the age group 65-74 and $8,600 in the group 75 and over. Persons with higher incomes had higher equity in their homes. Also, there was a higher rate of home ownership among persons with higher incomes. The higher incomes of owner households as compared to renter households result from the fact that a greater proportion of owner house- holds contain two or more persons. Among the 3.8 million single elderly persons who maintain their own households there is very little difference in income between owners and renters. For these one-person households median incomes for renters and owners were $1,200 and $1,100 respectively. The generally low incomes of these single~-person households indicate that many of them cannot afford decent housing. The homeowners, since they have some equity in their homes, are apt to be better off than renters and are likely to remain owners because they cannot afford suitable rental housing. Quality of Housing Older people are more likely than younger persons to have poor housing. In April 1960, over 19 percent of the 16 million housing units in which persons aged 60 and over lived were substandard in that they lacked private bath, toilet, or hot running water, or were structurally deficient. Only 15 percent of the households in which there were no senior citizens were substandard. Units occupied by households with heads under 60 years old were in better condition than those with heads 60 and over, probably because the younger household heads were still active in the labor force and so were likely to have larger incomes. Households headed by persons aged 65 and over are likely to have even poorer housing. Some 30 percent of such households had substandard housing in 1960. The relationship between housing quality and income is indicated by the fact that the median income among owners with adequate housing was ,400; while the median for owners of substandard units was only $1,500. Similarly, among renters, those with adequate housing had median incomes of $3,300 as opposed to $1,300 for those in substandard units. Mobility Households containing one or more older persons are less mobile than younger households. The census data showed that one-half of all house- holds moved at least once in the period 1955-1959, as contrasted with 30 percent of households with one or more senior citizens and with 26 percent of households headed by persons aged 65 and over. Some 30 percent of households containing one or more persons aged 60 and over--and 36 percent of those headed by persons 65 and over--had lived in their present unit for more than 20 years. Homeowners are less mobile than renters. Some 38 percent of the owner households with older members had lived in the same place for more than 20 years, as compared with 15 percent of the renter units. Among households headed by persons aged 65 and over, the percentages were 45 for owner-occupied units and 16 for renters. NEW HORIZONS FOR THE AGED Wilbur J. Cohen and Donald P. Kent The Federal Government is increasingly concerned with the well- being of older Americans. The majority of all Federal programs for elderly people are administered by the Department of Health, Education, and Welfare. For this reason, the Department has the responsibility to provide leadership in seeking constructive solutions to the problems of our older citizens. To help older people, one of the most important jobs that the Department of Health, Education, and Welfare can do is to make available all possible information and guidance--to the States and private organiza- tions that work directly with and for the elderly, and to the older person himself, to show him where to get the assistance he may need. Many Americans, and especially those of the older age groups who may no longer be continuously in touch with current developments, do not realize the extent of the services and assistance available to them. Nor are they aware of the scope of the projects and research that are being carried out to further their interests--work which is being done by universities, voluntary agencies, and State and local governments as well as by the Federal Government. Important gains have been achieved during the past two years both in legislation and in services, research, and pilot projects on problems of particular concern to the elderly. LEGISLATIVE GAINS, 1961-62 Federal legislation relating to the health and economic security of older Americans is developed, analyzed, and supported by the Department of Health, Education, and Welfare. Its staff members are the chief spokes- men in the Executive Branch of the Government for older citizens and testify to Congress in their behalf. In the past two years, the following important pieces of legislation of special interest to older citizens have been enacted: 1961 Amendments to Old-Age and Survivors Insurance These amendments improved the flexibility and effectiveness of the social security program, in that they: . Lowered the age at which men are first eligible for old-age and survivors insurance benefits from 65 to 62 (with benefits for those who claim them before age 65 reduced to take account of the longer period over which they will receive their payments). This change, which is similar to that previously established for women, has resulted in benefit awards to an estimated 740,000 persons. Mr. Cohen is the Assistant Secretary for Legislation, and Dr. Kent is the Director, Office of Aging, in the new Welfare Administration, U.S. Department of Health, Education, and Welfare. This analysis reflects administrative changes affecting the aged that were made in the Public Health Service effec- tive November 27, 1962 and in the Social Security Administration, the new Welfare Administration, and the Vocational Rehabilitation Administration (formerly the Office of Vocational Rehabilitation) effective January 28, 1963. Health, Education, and Welfare Indicators, January 1963 Revised 210 Raised the minimum benefit for a disabled worker or a worker retiring at or after age 65 from $33 to $40 per month. An additional $140 million has been paid aged beneficiaries because of this change. Increased widows' and parents' benefits by 10 percent, to a new total of 82% percent of the primary insurance amount, resulting in an addi- tional $105 million in benefits to approximately 1.6 million aged beneficiaries. Lowered the work requirements for eligibility for social security benefits from one quarter of covered work for each three calendar quarters elapsing after 1950 to one in four, thus enabling benefits to be paid to approximately 100,000 retired persons who would not otherwise have qualified. Liberalized the retirement test so that beneficiaries have less of their social security payments withheld when their earnings exceed $1200. As a result, beneficiaries have greater incentive to supple- ment retirement income with part-time or occasional earnings. It is estimated that an additional $35 million in benefits has been paid to 350,000 beneficiaries as a result of the new retirement test. 1961 Amendments to Old-Age Assistance Increased, from $12 to $15, the average monthly maximum for Federal sharing in expenditures for medical care in behalf of recipients of old-age assistance. Increased, from $65 to $66, the average monthly maximum for Federal sharing in old-age assistance payments, with the Federal Government paying up to 80 percent of this increase. Raised the ceiling on Federal grants to Puerto Rico, Guam, and the Virgin Islands for public assistance, thus enabling those jurisdictions to provide more adequate payments and better medical care for old-age assistance recipients. The Community Health Services and Facilities Act of 1961 This legislation makes possible a whole new approach to the care of the chronic conditions that now afflict four out of five older persons-- an approach emphasizing rehabilitation, restoration, and self-care. The law provides for: An increase from $10 million to $20 million in the ceiling on annual Federal appropriations for public and non-profit nursing homes under the Hill-Burton program. A five-year program of grants-in-aid to States for establishing and expanding out-of-hospital services primarily for the chronically ill and aging. Project grants to public and non-profit agencies for studies, experiments and demonstrations designed to develop new or improved methods of pro- viding out-of-hospital health services, especially for the chronically ill and aging. 211 As a result of this legislation, funds in the amount of $6 million in fiscal year 1962 and $13 million in FY 1963 were appropriated for grants to States on a formula basis of $1 of Federal funds for 50¢ of State funds for development of community health services to the chronically ill and the aged. Improvement or expansion of services in nursing homes leads in activities supported by these grants. For fiscal years 1962 and 1963, funds amounting to $8.3 million were made available for special project grants. To date, 54 projects have been approved in 27 States. Problem areas being explored in these projects deal with some type of home care services for the chronically ill and the aged. Other problem areas concern community organization for improved or expanded services, dental health, and referral services. A recent project grant under this program was given to the Age Center of New England for a study of methods of preventing dependency in later years. Working with one thousand older people in Boston, the Age Center will attempt, through an interviewing and counselling program, to help older people improve their perception and understanding of their own aging and, hopefully, discover resources within themselves to cope with their later years. Public Welfare Amendments of 1962 These amendments represent the most important legislation in the area of public welfare since the original Social Security Act of 1935. The amendments emphasize rehabilitation, the prevention or reduction of dependency, and the training of public welfare personnel. They liberalize assistance payments and give the States significant new tools for making welfare programs more effective. For the needy aged the most noteworthy provisions are: . Increased Federal sharing of the cost of certain rehabilitation services from 50 to 75 percent effective September 1, 1962. In the field of aging, such services are to be directed toward helping elderly assistance recipients to remain self-sufficient or, in the case of those who are disabled or institutionalized, to help them achieve a greater degree of self-care and return to thelr homes. Application of the T5 percent matching feature to funds for training personnel for State or local welfare agencies. Increase in the Federal participation in old-age assistance payments by about $4 per recipient. The temporary $1 increase in these payments provided by the 1961 amendments has also been extended. The ceiling for Federal matching is increased from $66 to $70. Since the Federal Government continues to share , to a $15 limit, in payments made directly to the suppliers of medical care in behalf of old-age assist- ance recipients, the average monthly maximum for Federal sharing in old-age assistance payments is now $85. 212 As a means of encouraging self-help, States are now required to take into account expenses attributable to employment in determining the need of an assistance recipient; formerly, such consideration was optional and not always given. States may exempt the first $10 and one-half of an additional $40 of earned income in determining the need of an old-age assistance recipient. To stimulate new approaches to the problems of the needy, demonstration projects and pilot studies are encouraged. The Secretary of Health, Education, and Welfare may waive State plan requirements in connection with such projects, and Federal funds up to $2 million annually are made available to help finance them. All of the States and territories are taking prompt steps to put the new provisions into effect. As of mid-September, 18 States showed increases in average payments because all or part of the additional Federal financial participation was passed on to recipients; five States were asking 75 percent Federal financial participation in services and training; and seven others sought 75 percent Federal financing for costs of staff training only. Drug Amendments of 1962 Since older persons are the heaviest users of drugs, this legislation has particular significance for them. The amendments establish new safe- guards for drug research, manufacture, and distribution, provide for more adequate information on drug labeling and advertising, and confer on the Department of Health, Education, and Welfare standby authority for stand- ardization of "generic names" for drugs. In particular, the legislation requires that new drugs be approved as effective, as well as safe, before marketing. Because older persons have lower than average incomes and higher than average medical care costs, it is most important that their medical care dollars not be wasted on ineffective drugs and medicines. Institute of Child Health and Human Development This legislation provides for the establishment within the Public Health Service of a new National Institute of Child Health and Human Development. This institute will conduct and support basic research on human development, employing an integrated approach to the study of the growth and development of man from conception throughout the life span. The studies of the aging process will be an important part of this work and the Center for Aging Research, formerly a part of the Division of General Medical Sciences, will become a part of the new institute. Other Legislation Certain Federal income tax provisions affecting the aged were liberalized by legislation enacted in 1962. The maximums on deductible medical expenses have been increased to as much as $40,000 if the taxpayer and his spouse are aged 65 or over and are disabled. Those with high incomes and high medical expenses will, of course, be the chief benefici- aries. Also, annuity plans which include accident, health, sickness, and medical benefits for retirees may now qualify for tax savings. Previously employers could take tax deductions for their contributions to employee pension plans only if the pension and health benefits were provided under separate plans. 213 Another amendment to the Internal Revenue Code liberalized the retire- ment income credit provisions so that people who do not get social security, railroad retirement, or veterans' benefits but who get other retirement income, such as government or private pensions, will get a tax credit that corresponds more closely to the tax preference given to recipients of social security, railroad retirement, and veterans' benefits. The Self-Employed Individuals Tax Retirement Act of 1962 makes a significant step forward in giving self-employed persons, such as profession- als and farmers, the same kind of favorable income tax treatment that is accorded to employees under qualified pension plans established by employers for the benefit of employees. The purpose of the new law is to encourage the establishment of voluntary pension plans by self-employed individuals. One- half of the self-employed person's fund set aside, up to a maximum of $2,500 a year, for investment into qualified retirement funds are deductible from current income for Federal income tax purposes, and the earnings on such funds will be entirely exempt from current taxation. The Senior Citizens Housing Act of 1962 provides additional funds for low and moderate cost housing, both urban and rural, for the elderly. The major changes accomplished through this legislation are in the rural housing program; direct loans mortgage insurance, and grants are provided. In addition, under the existing program of low-interest direct loans to pro- vide rental housing for the elderly, the appropriation ceiling for loans has been raised from $125 million to $225 million. Thus, the legislation enacted by Congress during 1961 and 1962 has been the basis for many of the advances that the Department has made in be- half of the elderly; it is also providing substantial aid to State and com- munity programs. GAINS IN SERVICES, INFORMATION, AND GUIDANCE, 1961-€3 Within the Federal government a number of Departments have responsibi- lities and programs related to the Nation's older population: the Departments of Agriculture; Commerce; Labor; Treasury; and Health, Education, and Welfare together with the Housing and Home Finance Agency, the Veterans Administration, and the Civil Service Commission. The Secretaries and other heads of these governmental agencies are members of the President's Council on Aging, which develops legislative proposals and plans other measures to strengthen and coordinate Government-wide activities benefiting the aged. The Secretary of the Department of Health, Education, and Welfare serves as chairman of the President's Council on Aging. A major role in the field of aging has been assigned to the Depart- ment of Health, Education, and Welfare. To expand and coordinate the Department's work, Secretary Celebrezze, effective January 28, 1963, has established a Welfare Administration under the Direction of Dr. Ellen Winston within the Department. The shift of the Special Staff on Aging, headed by a Special Assistant to the Secretary for Aging, to become the new Office of Aging within the Welfare Administration will improve coordination and aid in the expansion of services to the aged. The major components of the Department concerned with the problems of senior citizens, and the new Office of Aging that will serve as the focal point of that concern, are indicated in the chart that follows. 21k FOR PROGRAMS AND SERVICES FOR SENIOR CITIZENS ORGANIZATION OF THE DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE SECRETARY SOCIAL PUBLIC HEALTH SECURITY WELFARE OFFICE OF VOCATIONAL FOOD AND SAINT SERVICE _1/ ADMINIS- ADMINISTRATION EDUCATION REHABILITATION DRUG ELIZABETHS TRATION ADMINISTRATION ADMINISTRATION HOSPITAL Bureau of State Services Old-Age, Office of Aging Division of Consultant Office of the Geriatrics Division of Survivors, Panel of Continuing on Aging Commissioner Service Chronic Diseases and Consultants Education ... Consumer Gerontology Disability Departmental Adult Education Consulting Branch Insurance Committee Library Services Consumer National Institutes program on Aging Division of Education of Health Bureau of Family Vocational & Branch National Institute of Services Technical Bureau of Child Health & Old-Age Education Biological & Human Development Assistance Division of Physical Center for Aging program Educational Sciences Research Research Division of National Heart Cooperative Nutrition Institute Research Gerontology Division of Higher Branch Education National Institute of Mental Health Section on Aging This organizational structure reflects administrative changes affecting the aged that were made in the Public Health Service effective November 27, 1952 and in the Social Security Administration, the new Welfare Administration, and the Vocational Rehabilitation Administration (formerly the Office of Vocational Rehabilitation) effective January 28, 1963. 1/ Other offices devoting part of their resources to the elderly are: (a) within the Bureau of State Services the Nursing Homes Branch (Division of Chronic Diseases) and the Divisions of Nurs Community Heslth Services, Hospital and Medical Facilities (Hill-Burton), Dental Public Health and Resources, and Accident Prevention; ar (b) the Bureau of Medical Services. Welfare Administration The new Welfare Administration incorporates the Office of Aging (formerly the Special Staff on Aging), the related Departmental Committee on Aging and the Panel of Consultants, and the Bureau of Family Services (formerly a part of the Social Security Administration). The Office of Aging has over-all re- sponsibility within the Department of Health, Education, and Welfare for program planning, guidance, coordination, and public information and education on problems of aging. One of the principal activities of its predecessor organ- ization was to plan and conduct a conference of State Executives of programs in aging to extend the work of the White House Conference and regional levels. It subsequently helped to organize many national and regional conferences, including the 12 White House Regional Conferences on Senior Citizens, for which it had primary responsibility. In addition, the Special Staff on Aging provided technical assistance, consultation, materials, and directory informa- tion to State planning and coordinating agencies; to the President's Council on Aging; and to the foreign visitors, private organizations and individual educators, writers, and researchers. These efforts will go forward. Among the publications issued by the Special Staff on Aging were Reports and Guidelines from the White House Conference on Aging and a number of case studies of successful programs for older people published under the general title of Patterns for Progress in Aging. The monthly publication Aging con- tains news of activities in all parts of the country of particular interest to persons working in the field of aging. The new Office of Aging will con- tinue and expand such publishing efforts. 215 The Bureau of Family Services administers the Federal share of all the State programs for needy older people, including programs for medical care. One of the most striking developments in connection with the aged has been the decline in the number of persons receiving old-age assistance from 2.8 million, or 22.5 percent of the population aged 65 and over, in 1950 to 2.2 million and only 12.7 percent of the aged population in 1963. This trend is the more remarkable in view of the fact that the number of persons aged 65 and over in- creased by 5.2 million persons from 12.3 million to 17.5 million in the interim. Average monthly payments between the end of 1960 and March 1963 increased 10 percent from $68.45 to $76.67 due in part to increased Federal participation in assistance grants authorized by legislation passed in 1961 and 1962. The proportion of persons who concurrently receive old-age assistance and old-age, survivors, and disability insurance benefits rose steadily from less than one-tenth of the total OAA caseload in 1950 to slightly more than one-third of all OAA recipients in mid-1962. Much more needs to be done to provide adequate skilled nursing homes. At present about half of all persons in nursing homes and homes for the aged are supported by old-age assistance. The Bureau of Family Services works cooperatively with the Public Health Service and with State Departments of Welfare to improve the care of older people in nursing homes and other non- medical institutions and to establish and maintain standards for such institu- tions. The Department of Health, Education, and Welfare is actively working with the States to expand and improve the program of medical assistance for the aged under the Kerr-Mills approach. Authorized by legislation enacted in 1960, the MAA program by March 1963 included 29 States with programs in effect and payments in behalf of 118,000 recipients; total payments for the month amounted to $24 million, or an average of $203 per recipient. A substantial proportion of the MAA recipients during the initial months of the new program represented transfers from the old-age assistance rolls. Social Security Administration The Social Security Administration studies the needs and problems of older people, including income security, health security, and social needs. With respect to the aged, the Social Security Administration has considerably expanded its research. Previous studies were limited to persons directly served by Social Security income-maintenance programs, old-age, survivors and disability insurance and federally-aided public assistance programs. A new survey scheduled for January 1963 will be the first under the auspices of the Social Security Administration designed to measure the economic and social situation of a representative sample of all aged persons in the United States. Furthermore it will include persons 62 to 64 years of age--as well as those 65 years and over--to give some insight into the situation of persons Just approaching retirement, and those who elect to retire earlier under Social Security at reduced benefits. This survey will serve the needs of the statutory Advisory Council on Social Security financing which held its first meeting on June 10-11, 1963. In considering possible recommendations as to benefit levels and the retirement test provisions, the Council will need information not only for social security beneficiaries but also, on a comparable basis, for other aged persons. 216 OLD-AGE AND SURVIVORS INSURANCE AND OLD-AGE ASSISTANCE INDIVIDUALS RECEIVING PAYMENTS PAYMENTS MILLIONS MILLIONS OF DOLLARS 16 1,000 — — — 15 — # suf. Jos wt [] /! 14 + - 900 |- | - ® | J ~~ N B OLD-AGE, SURVIVORS, AND 7] OLD-AGE, SURVIVORS, AND DISABILITY INSURANCE DISABILITY INSURANGE iu (AGED ONLY) l/ 800 | = = 2 |- Eb - "= - _ 700 - - HUNCRED THOUSANDS 01 — Nn T — I= or] MEDICAL ASSISTANCE FOR THE AGED 600 — — oh lll 1 8 2H - } MILLIONS OF DOLLARS 500 40 , — MEDICAL ASSISTANCE FOR THE AGED 7 LHe et od |e — 30H =f = Sl - o opndigon | 400 — 201 J Jt M JS OM JS ole? 1960 1961 1962 ° |- JOH + sa) sel Sr = — -' 300 — 0 Libba bo bod ib wy mM J S 0 M J Ss 0 1960 1961 1962 4 I~ 7 — — sl 8 a 200 - — OLD-AGE ASSISTANCE ~~ eee ——— ———— E ASSISTANCE 2 . _ 100 - - | b= |. = hh bol en po fen fea 0 a chibi MAR. JUNE SEPT. DEC. MAR. JUNE SEPT. DEC. " = " " 1940 1945 1950 1955 1960 196! 1962 1940 1945 1950 1955 1960 198! 1962 1 Receiving old-age, wife's or husband's, widow's or widower’s, or parent's benefits. 217 AGED RECIPIENTS GF SOCIAL SECURITY AND PUBLIC ASSISTANCE BENEFITS, JUNE 30, 1962 Number2/ per 1,000 Number2/ per 1,000 population aged population aged 65 or over3/ 65 or over3/ Statel/ Statel/ Old-age Old-age 0ld-age Old-age survivors and| gssistance survivors and | gssistance disability recipients disability recipients beneficiaries beneficiaries Total .... (All Areas) 687 128 Rhode Island.... 785 68 Kansas. .creeeses 673 105 New Hampshire... 770 67 Virginia........ 667 Wr Maing. vurnrarns 768 10h California. .ieiw 665 176 Michigan...... ne 765 T9 Wyong. vs svew iv 663 98 Oregon. .o.veeuse 753 82 Maryland. oesess 658 ie) Connecticut..... 753 39 Florida. veer ve vw 657 151 Indiana......... 752 55 Missouric.c..... 655 ond New Jersey...... 46 31 South Carolina.. 6L1 187 Hawaii....oouees Thl Lo Arizona........ . 636 134 Wisconsin....... 43 75 Tennessee. ...... 636 158 Vermont. .ooesves 738 125 Arkansas...... - 630 279 Delaware........ 735 31 Colorado..eeeees 614 278 West Virginia... 730 98 Alabama........ : 60k 375 New YorK........ 728 33 Mississippi..... 602 Lo7 Pennsylvania.... 726 41 2 vin saa 593 279 Massachusetts... 720 101 Oklahoma. «eeoees 58 334 TABNO. vio ve vin wie » . 720 9k New Mexico...... 583 197 OhiOc ews tens wens 707 95 Georgi@..eeeeaone 580 308 Washington...... TOT 152 Alaska...... pa 579 227 North Carolina.. 699 1 Puerto Rico..... 570 292 I1linois........ 698 65 Dist.of Columbia 556 41 TOs wre we we wiv op 696 95 Iouisiana....... 521 502 North Dakota.... 692 103 Virgin Islands.. 430 266 Utah..... vit win vw + 689 107 Guam. ...... yuna 16 131 Montans. evs ves 688 91 South Dakota.... 686 110 Nebraska...... 2 685 80 Minnesota....... 679 120 Kentucky... sesess 67h 183 NevaBB.. oceans 673 131 Source: U.S. Department of Health, Education, and Welfare; Social Security Administration. _1/ Ranked by proportion of persons aged 65 and over who are OASDI beneficiaries. _2/ Persons receiving both OASDI benefits and OAA payments are included under both programs in the computation of rates. _3/ Preliminary estimate of the population aged 65 and over as of June 30, 1962, prepared by the Social Security Administration. 4/ Persons receiving old-age, wife's, husband’s, widow's, widower’s, and parent’s benefits; adjusted to exclude: (a) beneficiaries aged 62-64, (b) wife beneficiaries under age 62 with child beneficiaries in their care, and (c) duplicate counts for beneficiaries receiving both old-age and wife's or hus- band’s benefits. The survey will for the first time provide information nationally on the characteristics and financial circumstances of aged assistance recipients based on personal interviews rather than case records. It will permit analysis of the characteristics and resources of those aged persons who receive benefits from the Veterans' Administration, from other public pro- grams, or from private pension plans. The Cooperative Research and Demonstration Program of the Social Security Administration is also sponsoring research about the special needs and problems of the aged. Projects receiving grants in 1961 and 1962 included a study of early retirement, both from the point of view of indi- vidual satisfactions and as a means of adjusting the size and nature of the labor force to the changing needs of the economy. Another project is a study of the adjustment to retirement of a group of older persons followed over a number of years. An investigation of the decisions leading to institutionalization of aged persons is being made to shed light on the special problems of older people who are unable to care for themselves. Support has been given to a demonstration project which will provide protective services for older people in order to help them to continue independent living. Still another project being supported is a comparison of aged people residing in a public housing project with other low-income aged who applied and were turned down. The Social Security Administration is paying benefits to approximately 14 million aged persons, 1.6 million persons aged 62-64, and 12.4 million aged 65 and over. This represents an increase of more than 2 million aged bene- ficiaries since the beginning of 1961. Part of the increase is due to the liberalized requirements for insured status and the liberalized retirement test enacted by the 1961 Social Security Amendments. In the United States in mid-1962, some 68.7 percent of persons aged 65 and over were receiving old-age, survivors, and disability insurance benefits. By State, however, the proportion of persons receiving OASDI benefits varied from 78.5 percent in Rhode Island to 52.1 percent in Louisiana (Table). SSA administers the old-age, survivors, and disability insurance program through a network of district offices located in principal cities and towns in the United States and Puerto Rico. During 1961 and 1962, 26 additional offices were opened, making a total of 610. The district offices not only provide older people with information and assistance concerning social security benefits, but also furnish referral services to other governmental or community agencies pro- viding health, education, and welfare services. Increased emphasis is being placed on the service needs of beneficiaries, and district office personnel par- ticipate actively in local health and welfare councils and other community organi- zations concerned with the needs of older people. Public Health Service All programs of the Public Health Service have at least an indirect bearing on the well-being of the aged since they are concerned with the health of people in all age groups. Recently a number of programs specifi- cally concerned with older people have been developed. A Gerontology Branch, established in 1962 in the Bureau of State Services, plans, coordinates, and furnishes information and guidance for a more effective application of all knowledge affecting the health of the older age groups. 219 The Bureau of State Services, with project grants authorized under the Community Health Services and Facilities Act of 1961, is supporting a number of studies and pilot projects for the benefit of the aged. These include: (1) courses for health personnel who work in nursing homes; (2) courses in geriatric and restorative nursing; (3) out-of-hospital services for the chronically ill and aged; and (4) mobile dental units which bring dental care to chronically ill and aged people who cannot visit dentists® offices. Over half of the 44 community health project grants awarded by the Public Health Service in 1962 concern some type of home care--nursing, homemaker, physical therapy, community referral, and portable meals, among others--for the chronically ill and aged. The National Institutes of Health devote a considerable part of their medical research to the problems and illnesses of the aged. The Center for Aging Research, the Gerontology Branch of the National Heart Institute, and the Section on Aging in the National Institute of Mental Health concentrate exclusively on the health problems of the aged. Health Services Although most large cities have a number and variety of medical resources, community services often have grown up helter-skelter, with much overlapping, many gaps, and no planned system for efficient develop- ment and use of all facilities. An elderly person, with limited energy and meager funds, may have to go from agency to agency to find help. This causes serious and undue hardship. The Public Health Service recognizes the need for coordination of community resources to achieve continuity of care for the chronically ill and aged. Its programs are encouraging central referral and information services to help patients and their families find and use the needed health and social services. Accordingly, the Public Health Service has awarded grants to two large metropolitan counties (Dade County--Miami, Florida, and Monroe County--Rochester, New York) for long-range studies in coordination of health and medical services. These studies will consider organizational, administrative, and economic problems with a view toward welding all pertinent public and private organizations into a community-wide program of comprehensive health care. At the opposite end of the community scale, the Rip Van Winkle Foundation of rural Hudson County, New York (population 11,000) has been awarded a community health project grant to explore the possibilities of nonprofit supplementary services through a group practice clinic. The Foundation will provide on a non-profit basis home nursing, physical therapy, nutrition counseling, social case-work, a dental hygienist, and medical specialty consultation. Food and Drug Administration Much of the work of the Food and Drug Administration, although intended for the protection of the public as a whole, is of direct benefit to the aged. This year, for example, after seven years of litigation, the worthless arthritis remedy "Tri-Wonda' was driven off the market. The FDA 220 also eliminated from the market seawater which was selling at $1.95 a pint when advertised as a "chemical smorgasbord for ailing glands and organs'-- obviously intended to have a special appeal for the aging. Because older people are the largest users of drugs, all the efforts of the Food and Drug Administration in eliminating short weight or deceptive packaging and in ensuring the safety of drugs benefit the older age groups. Vocational Rehabilitation Administration One of the responsibilities of the Vocational Rehabilitation Administra- tion (formerly the Office of Vocational Rehabilitation) is to provide rehabili- tation services for the older disabled person. Grants from VRA for research benefiting the elderly exceeded $2.1 million in 1962. As a part of the in- creased emphasis on services for older persons, a full time consultant in aging was appointed in 1961 to work intensively with State rehabilitation agencies. A grant project in New York City resulted in the job placement of 197 handicapped men ranging in age from 60 to over 80. The success of this project stimulated the establishment of ten similar projects. In one project designed to explore work possibilities for older persons the Vocational Rehabilitation Administration is providing grants for a five- year program, launched in June 1962, to evaluate the response to regular employ- ment of selected disabled men and women over 60 years of age in Coney Island, New York. The disabled trainees will be assigned, on the basis of skills and preferences, to work on 25 to 30 products ranging from hardware to plastic toys. The project is designed to answer the following questions: Does employment ease tensions? Will these older, re-employed persons maintain, or even improve, in health? Will their intellectual competence be retained longer? Will their employment improve family ties? Office of Education The Office of Education took the lead in organizing regional conferences on education for aging which were held in seven large univer- sities during the past year. The topics covered three areas: education about aging, continuing education for older people, and educational and community services by older people. A new publication, Adventures in Learning--Frontiers Past Sixty in Hamilton, Ohio, is a case study of an action program developed in response to expressed interests of older people and designed to be of use to community leaders and educators. A home economist recently was assigned to work on training programs for the unemployed and underemployed--groups which are expected to include a high proportion of older workers. These programs will train workers as homemakers and in other family and home occupations, thus helping more older persons to find employment in serving other older persons--a two-way gain for the elderly. This undertaking is one of several measures made possible by passage of the Manpower and Redevelopment Act in 1962. Much has been accomplished during the past two years to improve health and social welfare services for older people. Expanded research activities in the area of aging have laid the groundwork for future progress. But much remains to be done. 221 GOALS FOR THE FUTURE IN SOCIAL SECURITY AND PUBLIC ASSISTANCE Adequacy of benefits is an important concern of the social security program. A major factor in benefit adequacy is keeping benefits in line with changes in prices and wages. As wages rise, provision should be made for corresponding increases in benefit payments; otherwise, these payments will more and more reflect the lower wages paid in earlier years and will become increasingly inadequate for the economic security of the retired worker. The question of how to keep social security payments in line with changes in levels of living will need continuing review. Basic to any consideration of the problem of keeping the program in line with the changing economy is the matter of adjusting the ceiling on the amount of earnings that can be taxed and credited toward benefits. Adjustments in the earnings ceiling to correspond with rises in earnings are important from the standpoint not only of keeping benefits up to date but also of keeping the financial base of the program from shrinking. PERCENT OF WORKERS UNDER THE OLD-AGE, SURVIVORS, AND DISABILITY INSURANCE PROGRAM WITH TOTAL ANNUAL EARNINGS COVERED AT THE CURRENT EARNINGS BASE, 1/ 1937 - 1962 Percent TTT TT TTT 1 YT —— yy —— T ———i > = Nr \ \ +— All workers 2/ 80 A . \ NU / I~ AL NN 7 6 yor — Regularly employed civilian men 3/ 50 \_ ic